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T A. - <br /> y <br /> SAN SOACU(N CL, USLIC HEAL79 SERVICES/£NVIRCNY.EHTAL HEAT ISION <br /> ( UGST '.'CRXSHEET FOR SITE CLOSURE EVALUATICH ATE It <br /> uAmE OF PACILITr �7yf 1.� ,.E,Ps coos 1b 1b <br /> n0R£SSY ANC I0 Y <br /> MANX SIZE IC,p UEL TYPE 146 <br /> it. C..c EEN RAC SITE HISTORY <br /> 17 IS acr.mit current? es , o crmic QQ !�f aci[ity Status Code /y/ oc.SoiL/G'1 Cont es a <br /> anter of Tanks at facility + ge of Tanks(if available) ypr of Tank feel prg[ ngl Ova[ <br /> Ill. TANY HISTORY <br /> ins Tank tested7 4es o ailed precision test 7 es o if yes, give-date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es o ere soil samples analyxed7 es o TXE PH-G PH-0 <br /> ype of failure/discharge atastrophic kLong-term leakage verfill known ther: <br /> JV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> So il Samples Received eso epth to Grourd l +n <br /> acer ° of/Year �6 z) verage Arua[ Precipitation k. 4 0-25 <br /> -Site Well(s) IYes o umber d Type ]rr Cm ub <br /> S Scare S Score S 5core <br /> istance to Well(s) from Tank ft; ft; ft G 0 pts C pts C pts <br /> i. <br /> 0 f 0 if 0 f <br /> Rondieion R, ondiCion R ondition <br /> slite Feature - Leaching Potential Analysis E is met E is met E s `net <br /> ini.mLrm Depth to grourdwater from the Soil Saople Veet) >100 I i-TOQ 25-50\l <br /> ractures in subsurface (applies to foothills or mosntain areas) Hone Unknown resent <br /> verage Amual Precipitation (inches) xxx=x <10 9. TO-25 xxxxxxx 26-40\2 <br /> __[ � <br /> an-made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unkna: resent <br /> iwe site features: Recharge area, coarse soil, nearby wells. At least are than <br /> xxxx None one one <br /> + j(� ; <br /> KN <br /> COLUTOTALS»>TOTAL POINTS <br /> I ample Result! (8 T X OR E) RANGE OF TOTAL POINTS 4 pts or more 41 48 pts 40 pts or .Less <br /> 81. � . P�' •ZJ! S T X E B T X E <br /> I <br /> KAXltaxi ALLOWABLE B-T-X-E LEVELS (PPM) ] 50 50 50 I .3 .3 1. I. NA\3 <br /> ample Result: ASOLTNE 1040 100 10 <br /> ]Filo ALLOWABLE TPN LEVELS (PPM)- <br /> i ��• TPH-6 IESEL 10,000 1000 100 <br /> CO1Nt)TES: "•If documcnced soil and/or ground water contamination is present, do not complete the [caching potential <br /> ann[ysis. (f.e., site is currently on UGT Contamination List for sol[ or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth ­5 ft., do not use table. <br /> a \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for 3TX&E are nae applicable at a-TPH concentration of 10 ppm (gasoline) or 500 ppm (diesel). <br /> i <br /> STAFF RECCWENDAT[ON/CONCLUSION <br /> 4 1. Are 3TX E or TPH Concentrations > Allowable Levels Yes o <br />+ 2. Re--oamerd Site Closure 1Y <br /> es o If Yes, Refer to Site Mitigaci m for Evaluation <br /> it. REVIEW EVALUATIM - TO BE CCHPLETED BY A SUPERVISOR/SENIOR <br />{ .CNCJR WITH STAFF RECCHMENDATION FOR CLOSURE ES 0 EFERREO TO SITE HITICATICN FOR =VALUATION ES 0 <br /> h <br /> ATE REFEARED / / ATE CLOSURE LETTER MAILED 7n / <br />{ <br /> i LANE OF <br /> r ;'IALUATCR <br /> EN 23 !0 (UGTVKSNT)\5/90 <br />