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t <br /> SAN :OAajim COI0-PUBLIC HEALTH SFRVICES/ENVIRONMENTAL HEALT'. �""SIOH <br /> t. UGST VORZSHEET FOR SITE CLOSURE VIALUATICH ATE ����F <br /> AME OF FACILITY I G EPS CODE <br /> nORESS U GC. ANK to �5 Q <br /> tANX SIZE �0 EL TYPE <br /> It. GENERAL SITE HISTORY <br /> Is permit currenc7 es o ermit 3 - )Facility Status Code oe.Soil/CJ Cont Ires o <br /> umber of Tanks at facit icy ge of Tanks(if available) Irype of Tank tee) brgl ngt Ouat <br /> IIt. TANK HISTCRY <br /> l <br /> as Tank tested? es • o ailed precision test ? 16s o If yes, give dace(s) <br /> as a repair made to the Cank system? IYes No 11f yes, what was repaired? <br /> as repair done under inspection) es qQ dere soil samples analyzed? es o TXE PH-G I PH-0 b/Soa I <br /> ype of failure/discharge atastrophie Lang-term leakage erfilt cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEAC'IING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water jqC1, of/Yearg 0 verage Annual Precipitation = I1G 0-25 <br /> -Site Wett(s) es ' o umber b Type irt,"am <br /> S core S core S core <br /> istance to WeLL(s) from Tank &() ft; ft; ft C 0 pts C pts C pts <br /> 0 if O if O f <br /> R ondicicn R ondition R ondicion <br /> Site Feature - Leaching Potentiat Analysis 7 E 's met E is met E s met <br /> inia m Oepth to groundwater from the Soil Sample (feet) >100 i 1-100 I S 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown present <br /> verage Arcual Precipitation (inches) CLXXXX <10 1 9 110-25 x x 26-1.0\2 <br /> an-made conduits smith increase vertical migration <br /> f teschate (i.e., septic systems, water wells, ponds) None Unknowns reserve <br /> nide site features: Recharge area, coarse soil, nearby welts, l I At teasel are than <br /> None 9 ,f one one <br /> COLUMN TOTALS»>TOTAL POINTS i C + I � } 1 V <br /> ampte Result: (a T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts GO pts or less <br /> ,4 ,1 N D 11T IX E B T X E <br /> HAXI)ti?I ALLOWABLE B-T-X-E LEVELS (PPN) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> ample Result: LINE 1000 100 10 <br /> AXIMUII ALLOUABIE TPH LEVELS (PPM) <br /> /�- iPH fESEL 10,000 1000 100 <br /> FOOTNOTES: "'If documented sail and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and < Z5 ft., score 0 points. If depth <_5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levets for BTXLE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> 1. STAFF RECCt9MENDATION/CCNCLUSIO9 -Tt <br /> )tj,�Gd ;S�i Yt C&k7`fCl�rrrrCst Ce <br /> I. Are BTX &E or TPH Concentrations > Allowable Levels Yes o ;,,��) !Cl-xak—"�3 <br /> 2. Recommend Site Closure F77 <br /> if Yes, Refer to Site Hitigation for Evaluation <br /> It. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCJR WITH STAFF RECCMMEHOATION FOR CLOSURE SES EFERRED TO SITE %fIrtdATrCH FOR EVALUATtCH ESI 0 <br /> ATE REFERRED / / ATE CLO§URE LETTER WAILED j <br /> :AME OF <br /> :VALUATOR <br /> EH 23 80 (UGTIIXSHT)\5/90 <br />