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SAH JOAOUIN COUNTY '' IC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> UGST $SHEE �j Z�T FOR SITE CLOSURE EVALUATION OATS -IL <br /> SVEW CODE <br /> NAME OF FACILITY i <br /> JADDRESSC7 TANX to 0 ! e/ —z> to <br /> r <br /> Q 1� (r�Y r-� <br /> TANK S I ZE J vvd'4L7b FUEL TYPE / Z- 1 h Y <br /> i <br />[. GENERAL SITE HISTORY rrr i' <br /> Is perafc current? Yrs r•' No Permit - Facitity Status Code DOa.2OIt/GLI Cont Yes No t 'r <br /> Hunbrr of Tanks at facility Aye of Tanks(if availabte) Type of Tank Steel Fbrgt Snyl Duel <br /> II. TAMX HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 Yes No if yes, give dates) <br /> E <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No ; Were soil saaptes anatyzed? Yes No atxE TPH. TPH-D Pb/EDB <br /> .. �� <br /> Type of fafture/dischargecatastrophic long-term leakage overlitt unknown others :� I <br /> .._ ...... . .. '.4 <br /> IV. ;ZE!+CVAL HISTORY (ATTACH INSPECTION REPORT fat SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS)-,,:,. <br /> Avetage Annuat Preelpttation A= 14 10-25 ! <br /> Soit Samples Received Yes No Depth to Ground Vater Ref/Year ; : .. _ .-. <br /> Cn-Site 'aett(s) Yes No Humber L Type Irr Dom Pub S Scare S Scare S Store f <br /> Distance to WetL(s) from Tank ft; ft; ft C 10 pts sN C 9 ptl ;- C <br /> a If o rf ,,0 if x <br /> R condition R Condition R concittron� , <br /> V. Site Feature - Leetthiny Potential Anetysis E is met E it Ant"' '"e it diet r <br /> ..t <br /> 31100 51=100 25-50\S ; <br /> yfnfmue Depth to groundwater from the Soil,Saapte (feet) �.... <br /> •. umflown Present ` '1 <br /> Fractures In subsurface (appties to foothilts or mountain areas) None ; <br /> Average Annus! Precipitation (inches) <br /> xX=. <10 9 tri-2S xiixxxxx <br /> Man-mace conduits which 'Increase vertlzsl migration I „� t ,r � 1r 4�` a k"..,• <br /> IYit T Pro=em' <br /> of leachate (i.e., septic systems, water.wetls, ponds) <br /> At taut Nor* than { <br /> Unique site features: Recharge,aces,{eoa yse sol`; nearby +cells: xxxxxx Nona vi _ � ..,,..,. one <br /> l <br /> COLUMN TOTALS»31TOTAL POINTS <br /> !" <br /> RANGE OF TOTAL POINTS 69 pit or mora ;1 ; 41 pCs "''60 pts'60 tris ti <br /> Samile Xe�u't: (B T xlt9 E) rt <br /> ..:. :r .. <br /> Ir <br /> M /7 <br /> Z .y PI B T X E a , # ! f. <br /> .x t "') . <br /> �0 {f' :`` K0IKM'ALLOWIBLE 2-T=X-E LEVELS IPPR) 1 50 50 50 .3 .3' `1. 1!1►\3 f <br /> GASOLINE - loco 100., <br /> lSvVte Resutt: _ <br /> -OUMU TOM LEVEL <br /> liAXiMUM ALL S CPPM) <br /> DIESEL i. 10j000.. ;"a..:J;. l00 <br /> FOOTNOTES: r"If documented toil and/or growid Yater cdntsm1cwtion to present; do not caaplete 66,1460114 potential <br /> anatySi#.`(t.j.;"site is currently an UGT Contamination List for soil or-ground water:)-.'W": c ? i <br /> \1 If depth is > 5 fi.S ..e 2S ft., score 0 points:,If depth —S ft_:; do nottuse•tabte. <br /> \2 If precipitation Is > ;0:inehes, score 0 points. y� ' <br /> \3+Lavela for 8Txi8 ah�not,applicab(e at a TPH concentration Of ld PPMCOGSOtine)'0"00 ppdi (dteset): <br /> VI. STAFF RECoKKENDATION/CONCLUSION �u E:! fw w. - ►7�" r,a.,-t. ; <br /> x <br /> 1. Are ST; L E or TPH Condentratlaft Allowable Levels *Yes No <br /> 2. Recommend Sit* Closure Yes No <br /> If Yes, Refer to site Mitigation far Evalwtian Fad rP;.tr1. <br /> Vif. REVIEW EVALUATION • TO Of COMPLETED, Y A SUPERVISOR/SENIOR <br /> FOATE <br /> R WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE 141TIGATIOM'FOR EVALUATION YES NO <br /> REFERRED ! / DATE CLOSURE LETTER MAILED #, <br /> OF .r - <br /> EVALUATOR <br /> EH 23 Sa (UGTWKSNT)\5/90 _ <br /> .. t <br /> a <br />