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SAN 1CACUIX CCU. NW C HEALTH SERVIC:S/ENVIRONMENTAL HEALT. VISICH <br />:. UGST V=SHEET FCR SETS CLOSURE VALUATICH (OATEJ J ` <br />NAME OF FACILITY a I S-wE:PS CSE 1 <br />woaEssl ` , 21TANK to x1 <br />TANK StZEf � ! FUEL TTP£} }°j/ <br />GENE -IAL SITE HISTORY <br />m <br />yIs peraic current?Yes1No Permit tj 7 `Facility Status Coder Doe.Soit/G.i ContlTesj No <br />NunDer of Tanks at faeili yj IAgo of Tanks(if available)I Type of Tank ISteel j Fbrgij (Sngll Dual <br />IEE. TANK HISTORY <br />Was Tank tested? jTe3 Xoj lFaited precision last ?IY"I IXO Iif yes, give date(s)I <br />iYas 3 repair made to :hs tank system? IYes I Na <br />jIf yes, what was repaired?I <br />1Was repair done isnder inspection? <br />Yes jNo) (Vere soil samples analyzed?IYes I Ime 1 <br />STXE1 ITP4-GI ITPH-01 jPbleaj <br />Type of failure/discharge Icatastro;hicj tong -term tsakagel overfill] uNmowni other: <br />iY. .2E.MCYAL HISTORY (ATTACS IXSPECTICU IUMT FCR SITE OETAILSIMLLEC OATA FC2 LEAMING POTEXTIAL ANALYSIS) <br />'Sail samples 2ecaivedlyesf No Depth to Grarc! Watorlio jRef/'Sear jAverige AnrsmL Precipit3tionIA=114 <br />110 -ZS <br />On -Site VeM s)IYes1 INo jXuaber G Typal jIrrj 10=1 I Pvbj <br />S <br />C <br />0 <br />R <br />_ <br />Scare <br />10 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Scare <br />9 pts <br />if <br />corxtithon <br />is met <br />S <br />C <br />0 <br />R <br />Scare <br />5 pts <br />if <br />ccriditicn <br />is met <br />IOistance to WeLL(s) from Tank] ft; ft; ft <br />jV. Site Feature - Leaching Patencial Anatysis <br />1Miniassa Depth to groundwater fres the Soil Sample (feet) <br />1 <br />>t00 15t -t00 j <br />I <br />25-50\1 I <br />IFrsctures in subsurface (applies to foothills or mors ncain areas) <br />(% <br />I None 1 1 Unkrmwn j <br />]Present <br />1Aver3ge ArcxAL Precipitation (inches) <br />xxx xj <br /><10 <br />j 9 1 10 -ZS lx=xx=l <br />25-40\2 <br />�'Man -dada conduits which increase vertical ai ration <br />of Ieac.hate (i.e., septic systema, water welts, ponds) <br />j <br />f <br />Naga <br />I Uriano++rs <br />Present <br />'Unique site features: Recharge area, caarss soil, nearby wells.qave <br />I <br />f I At lea <br />(More :� <br />CXX.Ik4! TOTALS>a>TOTAL ?LINTS <br />Samcte .2esul:: (3 T X CR _) <br />} <br />RANGE OF TOTAL POINTS <br />49 pts or more 'I - 48 pts ( 40 pts or less <br />MAXIXX ALLOWWL: 3 -T -X -e L_cYELS (PPM) <br />3 <br />t� <br />T :0` X 50� <br />- 50 <br />. 3 3 <br />3 <br />J.T <br />tX.I <br />- <br />t. <br />Sa=te Result: <br />TPH <br />MAXI" ALLOW48L.° TPI LEVELS (PPM) <br />GASOLINE <br />5000 ( 100 1 t0 <br />DIESEL <br />10,000 j 1000 1 100 I <br />'F CTACT_S: "'"If documented sail and/or grmrsd water contaminati0n is present, do not eanoleta the Leaching potential <br />anitysis. (i.s-, site is currently on UGT Contamination List for sail or grotzd water.) <br />\t If depth is > S ft. and < Z5 ft., scare 0 points. it depth a5 ft., da not use tabu. <br />\2 Ef precipitation is > 40 inches, scars 0 points. <br />` \3 Levels for 3TXSE are not appticabts at a LPI comentration of 10 ppm (gasoline) or 100 --;= Cdiesat). <br />`/i. STAFF .AECCWENOATICN/=C:.I.'SICX <br />1. Are 3TX b _ or TPH Cancerurstiaa a Alio„aabts Levels ('Ye31 IN'' <br />Z. ZecSita Clasurs�Yes' 1X01 if Yes, 2sfer to Sita Mitigation far "cvaluation1 <br />{1I. .IVIEV :lALUATICX - TO 3E C.7tPt-TM 3T A SUP4_MVISCR/S'cYIG2 1 <br />=N=2 VITH STAFF ..19C= tENOAT CX :CZ LCSLUMjTES► I901 `2EFERR ] TO SITE MITIGATICX FC2 EVALUATICNITESi INO1 <br />SCAT -c 2EF=2RE01 /. / IOATE C::st..2E u-' ER MAILJI <br />(NAME CF <br />`c.IALUATC2 <br />