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SAW "QUIN Cf i PUBLIC HEALTH SERVICIVERVIPONMENTAL REALIVoW"PISTON <br /> 11 UGST WORKS3EET foR SITE CLOSURE EVALUATION ATE <br /> AME OF fACILI ESPS C <br /> PORES ANK 10 A 9, <br /> tANK size <br /> 11. GENERAL SITE HIS RY <br /> Cont es 0 <br /> rvt iTAt <br /> f1f. TANK HISTORY <br /> ' s Tank test i cited pre isi test If yes, give date(s) <br /> as a repair c to the atiK ss Na Yes# hRt gasrepaired? <br /> As repair, lyzed? es to TRE P"_G PH-D /E08 <br /> IV. PEMOVAL HISTORY CATTACH INSPECTION REPORT FOR SITE DSTAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> 0i i Smote$ R i verage Annual 0 <br /> Precipitation 4 -25 <br /> 3 <br /> -Site wet(($ <br /> core S core S tore <br /> fStence to We C 0 Pts C Pts C pts <br /> 0 0 if 0 <br /> 4 -ondition R< ition R ondition <br /> Sit* Feature - teaching Potential Analysis E is met E Is met E <br /> imfiun Depth to groundwater from the Smit Sampte (feet) )'100 1-100 <br /> ractvres in subsurface (applies to foothitts or ffountain sreas) NoneIIr�R resent <br /> verage Annual Precipitatiom (inches) xxxxx <10 9 10-25 Kxxxxxx 26-40\2 <br /> N%w <br /> an-Made conduits Which Increase vertital migration <br /> f teachate (i,e., septir, system, water wells, ponds) None Unknown resent <br /> Inique site features. Recharge area, toarse soft, nearby wells. At teast ore than <br /> xxxxx None one on e <br /> I-' <br /> COLUMN TOTALS>*>TOTAL POINTS + /91 + 23 <br /> smplu# Resutt: (3 T A OR E) RANGE OF TOTAL POINTS 9 pts or mre 41 48 jots 40 pts or tess <br /> 8 T X E 8 T X E <br /> MAXIMUM ALLOWARLE G-T-X-E LEVELS (RPM) 1 50 so 50 .3 3 1. 1. 6;iNA\3 <br /> ) <br /> ample Resuitz ASOORE, 1000 100 tO <br /> 1660 TPH 4AXIMUM ALLOWABLE TPH LEVELS (RPM) IEUL 10.000 1000C,0�0 <br /> OOTNOTES: ***If doctrotnted slit and/or ground water contamination is present, do not tate the teaching potential <br /> srwiiysis� (i.e�, site is currentty on UGT Contamination Listw for soft or ground water.) <br /> \1 If depth is > 5 ft. " c 25 ft., score 0 points'. If depth -5 ft., do not use tabte. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> t a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> R� r Site Ctasre es � � if Yes, Refer te> Site Fist€gatiw Or Evil ti <br /> V11, REVIEW EVALUATION - TO SE COMPLETED BY A SUPERVI$OR/SENTOR <br /> EC4CUR WITH STAFF RECOMMENDATION fOR CLOSURE es EFERRED TO SITE MITIGATION FOR EVALUATION 6 0 <br /> ATE REFERREO ATE CLOSURE LETTER MAILED <br /> AM9 OF <br /> .VALUATOR <br /> E77= <br /> Em 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />