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■ <br />SAN 1CACUVM' SL:C HEALTH SERYIC2S/SUVtRCNMENTAL HEAL,:& ICN <br />I UGS, ',CRXSHEET PCS( SITE CLCSitRE VIALUATICH OAT-cl <br />(NAME CF FAC:L:71 ( `SwEEPS =F.I <br />IADORESSI ITANX to $1 . <br />ITANX 3t2EI (FUEL TYPE( ` <br />II. Gc'HE.QAL SITE HISTORY <br />IIs perait current? Iyes l INoI Permit !� - (Facility Status Cade IDoc.SoiLIM4 CantYesINo` <br />lxumer of Tanks at facility} (Age of Tanks(if available)' Type of Tank ISteell Fbrgll ISngI) Duatl <br />Ili. TANK 31STCRY <br />Was Tank :ested7lYesl No (Failed Precision test 1 Yesl INoI If yes, give date(s)I <br />(Vas a repair sole :a the esnk syzt=?Iy sl No (If yes, what was repaired?( <br />luras repair done .rider inspection?I7es INal Iyert soil smptes analyzed?Iyes f INOI STXEI ITPH-GI ITPH-0I Pb/EDB( <br />Type or failure/di3charge !catastrophic! (Long -Cera leakage! overfill! unkrxs+.nl other: <br />.2�r'4CVAL HISTCRT (A7TAC'� INSPECT40M REPCZT FCR SITE 0£TAILSIMUC' OATH FCR LEACHING POTENTIAL ANALYSIS) <br />Soil Saaptea Received las) (Hol Depth to Grotr�d Valet IRef/"eu ; IAverage Armat PrecipitationlAs114 <br />110-25 <br />Cn-Site Vetl(s)Iyes I (NeI INumer L Typel IIrrI 1DcmI IPvbl <br />S <br />C <br />0 <br />R <br />Score <br />10 Pts <br />if <br />tend{tion <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Scars <br />9 Pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />Scare <br />5 PCs <br />if <br />cznditien <br />is met <br />Oistame to Veils) from Tat*! ft; _f t; ft <br />V. Site :tsture - Ltaching Potential Analysis <br />Minim= OepC.h :a grou-water from the Sail Sample (feet) <br />I <br />I >1Q0 ( I51-100 I <br />125-50\t <br />�Frae:::res in subsurface (applies to foothills or =ouncain areas) <br />l I Nave I i Unknown l <br />!Present <br />Average Armat Precipitation (inches) <br />xxzrcxxl <10 l 9 110-25 I rl <br />zs-40 2 <br />jMan-Aade conduits which increase vertical Yigrstiat <br />poi Lsachate (i.e.. septic systema, water watts, pordds) <br />I Name <br />I <br />Unkn <br />I <br />IP enc <br />(Unique site features: Recharge area, coarse soil, nearby wells.I <br />xa <br />xx Mahe <br />I I <br />At least) <br />anal <br />Wore than <br />one <br />7-i <br />I <br />'M <br />� =LtTOTALS»> T QTAL POINTS <br />I • <br />I ( <br />' <br />I <br />I= I <br />�Saocke Iesut-.: (3 T X .7 <br />RANGE CF TOTAL ?OINT3149 <br />pcs or acre I 41 - 4a Pts I 44 Pts ar less <br />MAXIM9l ALLCYA8L° 3-T•X-? Lnas %PPM) <br />tI <br />T04 504 <br />50 <br />I .3 '�.3 <br />t.4 <br />1. <br />I NA\3 I <br />�Saa9pte Result: <br />IPH <br />MAXI" ALLCWLUVELS (PQM) <br />E TPN <br />GASQLDIE <br />1000 ( 100 I to <br />DIESEL <br />10,040 I Cann i 100 I <br />'F'XITNCT---S: 1'014, documented soil arWor grouid water '-Oncaminaticn is present, do not ccmmtets the Laaehinq patrncial <br />analysis. (i,l., site is currencly an UGT Cantaminscion List for sail or ground water.) <br />\1 If death is > 5 ft. axi < 25 ft., scars (3 points. if depth —5 ft., do noc =e table. <br />\2 If prtcipitaticn is > 40 incises, SCOT! 0 Points. <br />1 \3 Levels for 3TX&E are noe apatiesble at a LPH caxencratian of 10 X= <3asotina) or 100 ppm (diesel). <br />111. STAFF RE=41E.'IDATICN/=XC=StCM <br />1 T. Art 3TX b = or TPH Carheancr3t4Cm > Allouaole Levels I'*Tesl !No) I <br />j Z. Recaainend Sita C:asurt{Teal INo} L'If Yes, Refer :a Site Mitigation for=valuntfonl <br />tt1. .IFITEii _IALUATIM - TO 3E C2WU1:M 3T A SUPRYISCRISE.14IC2 <br />CNC:2 'JITH STAFF REC=44MAT:CA ;-t2 LCSUR£IYESZ NCI I2EiaM- TO SITE MITMATICH FCR 'VALUATTCH17£S# (Nei <br />IDA'I-E ER AAILMI <br />(NAME -F <br />c•/AU;ATCR <br />.i 30 (1.17 .XSHT}\5/90 <br />