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r- SAX J+OACUIN C*PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALT�VIStOH DATE <br /> VCRZSHEET FCR SITE CLOSURE EVALUATION <br /> SWEEPS C:OOE <br /> NAME OF FACILITY -� T ARK 10 tt <br /> CJS <br /> ADDRESS S <br /> TANK SIZE cpcp FUEL TYPE / <br /> :ter <br /> I. GENERAL SITE HISTORY <br /> Facility Status Code SZ Doc•Soil/GW Can Yes No <br /> Is permit eurren Yrs No Permit �z 2 3 Q O <br /> 3 <br /> Age of Tanks(if available) <br /> Humber of Tanks at facility 1��, Type of Tank Steel Fbrg Sngl D <br /> Al. TANK HISTORY <br /> 'Was Tank tested? e <br /> No Failed precision test 1 Yes No If yes, give date W / <br /> iWas a repair made to the tank SYS em? Yrs <br /> N If yes, what was repaired? <br /> Was repair done under inspection? as No Were soil seaples analyzed? Yes „No BTX--- <br /> if <br /> TPH-G TPH-D - Pb/E0g <br /> Type of fail ure/dis charge catastrophic long-term leakage overfiurkne other~. <br /> 711. REMCVAL HISTORY (ATTACH INSPECTICU RE?CRT FOR SITE DETAILS/COLL CT DATA L CHI NG POTENTIAL ANALYSIS) <br /> Soil Samples Receiv Yes No Depth to Crourd Vater q Ref/Tear ; <br /> Average ArYwal Precipitation As 14 10-25 <br /> No NuoSer L Type ? Irr Dom Ptb S Score S Score S Scare <br /> On-Site Wells) Yes <br /> C 10 pts C 9 pts C 5 pts <br /> � � <br /> Distance to Wells) from Tank ? ft' _ft; ft 0 if 0 if O_ if <br /> R condition R condition R condition <br /> E is met <br /> E is met E is met <br /> v. Site Feature - Leaching Potential Aralys's >100 51-100 25-50\1 <br /> IMinim.rs Depth to groCndwater from the Soil Sample (fret) Unknown Present <br /> X one <br /> Fractures in subsurface (applies to foothills or mountain areas) 9 10-25 xxxxxxx 26-40\2 <br /> i xxxxxx <10 <br /> Average Annual Precipitation Cinches) <br /> Man-Made conduits which increase verttul migration <br /> Norge of <br /> Present <br /> of leachate (i.e., septic systeasI water wells, ponds) <br /> At least � More than <br /> Unique site features: Recharge area, coarse soil, nearby wells' zxx=x None one one(a _1 <br /> COLUMN TOTALA»TOTAL POINTS 40 s ar less <br /> RANGc OF TOTAL POINTS 49 pts or more 41 - 48 pts <br /> Sacple Result: (3 T X CA E) B T X E <br /> B T X E NA\3 <br /> WI" ALLCUABLE 3-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 10 <br /> GASOLINE 1000 100 <br /> Sample Result: MAXI" ALLOWABLE TPH LEVE LS (PPM) 1000 100 <br /> DIESEL 10,000 <br /> O 000 TPH is do not complete the leaching potential <br /> *"If documented SOIL and/or ground water conUnationtamon imticntList for soil or ground water.) <br /> FOOTNOTES: analysis. (i.e., site is currently te GT nts. If depth —5 ft., do not use table. <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 poi <br /> \2 If precipitation is > 40 inches, score 0 points. asoline) or 100 ppm (diesel). <br /> \3 Levels for 3TXIE are not applicable at a TPH concentraticrt of 10 ppm C9 <br /> VI. STAFF gECcmME4DATICN/CONCLUSIC9 <br /> 1. Are BTX b E or TPH Concentrations > Allowable Levels 'Yrs No <br /> 2. Recortmecd Site Closure Yes No <br /> It Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALU1lTION - TO SE CO PLETED 3Y A SUPERVISCRISOENICR�r�� TO SITE MITIGATION FOR EVALLUITICN YES NO <br /> t:CNC.lR WITH STAFF RECCx44EN0A1ICN FCR CLOSURE YES / <br /> / DATE CLOSURE LETTER MAILED <br /> GATE REFERRED / - <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWXSHT)\5/90 <br />