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I. <br />NAME OF FACILITY <br />AOORESS <br />TANK SIZE U FUEL TYPE <br />II. GENERAL SITE HISTORY <br />P WORKSHEET FOR SITE CLOSURE EVALUATION <br />DATE 11,1 <br />rP?� <br />NX 104=4. D Z_ <br />Is permit current? <br />Yes <br />No v1permit II <br />- N <br />Facility Status Code <br />Doc of /Gil C <br />No <br />! ! <br />Number of Tanks at facility <br />NAME JF <br />Age of Tanks(if available) <br />Yes <br />Type of Tank <br />Steel <br />If yes, what was repaired? II <br />Fbrgl <br />Yes <br />Sngl <br />Dual <br />III. TANK HISTORY <br />Was Tank tested? <br />Yes <br />YES <br />No <br />NO <br />Failed precision test 7 <br />Yes <br />! ! <br />No If yes; give dates) <br />NAME JF <br />was a repair made to the tank system? <br />Yes <br />. No <br />If yes, what was repaired? II <br />Was repair done under inspection? <br />Yes <br />No <br />Were soil samples analyzed? <br />Yes No <br />BTXE <br />TPH-G <br />TPH-B <br />Pb/EBB <br />Type of failure/discharge <br />catastrophic <br />long -terve leakage <br />overfill <br />unknown <br />' <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />,: <br />Soil Samples Received Yea MCI I <br />Depth to Grand Water Ref/Tear all Average Arcual Precipitation As 14 10-25 <br />On-site Wells) Yes No Number & Type Irr Dom <br />S Score S Score S Scare <br />Distance to Well(s) from Tank ft; ft; ft C ]Opts C 9 pts C 5 pts <br />a if,¢ 0 if 0 if <br />R. condition R condition R condition <br />V. Site Feature - Leaching Potential Analysis E is3met E is met E is met <br />Minimum Depth to groundwater frac the Soil Sample (feet) >100 51-100 25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) None Unkrawn Present <br />Average Annual Precipitation (inches)xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br />Man-made conduits which increase vertical migration 1'i <br />of leachate (i.e., septic systema, water wells, ponds) !lane Unmown Present <br />Unique site features: Recharge area, coarse soil, nearby wells. At Least More than <br />xxx= Hone ane one <br />COLUMN TOTALS»>TOTAL POINTS <br />+ + <br />Sample Result: (S T X OR E) RANGE OF TOTAL POINTS 49 pts oP,more s 41 - 49 pts 40 pts or less <br />B T X� E B T X E <br />MAXIALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 501. 1. NA\3 <br />Sample Result: GASOLINE 1000 100 10 <br />MAXIMUM ALLOWABLE TPI! LEVELS (PPI!) <br />TPN DIESEL 10,000 1000 100 <br />FOOTNOTES: —if documented soil and/or ground water contamination is present, do not complete the leaching potential <br />analysis. (i.e., site is currently an UGT ContaminatiaZ List for sail or ground water.) <br />\1 If depth is > 5 ft. and < 25 ft., score 0 points. it depth a5 ft.;. do not use table. <br />\2 If precipitation is > 40 inches, score 0 points. 'i <br />\3 Levels for BTXSE are not applicable at a TPH concentration of 10 gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOMMEMDATION/CONCLUSION A! 1'25v1-� KCf6Z) <br />i. Are BTX & E or TPH Concentrations > A owabl s 'Yes Na�� <br />hrxh/ N D. !- +�u 5'k 1s cd,-l�A l <br />2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO 3E CCMIPLETED BY A SUPERVISOR/SENIOR <br />CDNCJR WITH STAFF <br />ZECCMNDATION FOR CLOSURE <br />YES <br />NO <br />REFERRED TO SITE MITIGAT FOR EVALUATION YE5 NO <br />DATE REFERRED <br />! ! <br />DATE CLOSURE LETTER MAILED <br />NAME JF <br />EVALUATCR <br />Ij <br />EH 23 80 (UMM SHT)\5/90 <br />