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IBLIC HEALTH SERVICES/ENYI0.0NHENTAL HEALTH " "',IStON DATE /Z 20 Qt// <br /> SAM lOACU[N � g,..<ORXSHEEL FOR SITE CLOSURE EVALUATICN <br /> LO yE /�L SNEEPS CODE <br /> MAH£ OF FACILITY •yb���O71 _ <br /> TANK IO 0 <br /> ADDRESS 2(b C . <br /> TANK SIZE 5,00 FUEL TYPE <br /> 1. GENERAL SITE HISTORY Doc.Soil/Ov Cont Yes No <br /> Penit a Facility Status Code <br /> Is permit currencT Yea Dual <br /> Nvrber of Tanks at facility � <br /> Age of Tanks(if available) Type of T Steel Fbrgl <br /> '.I1. TANX HISTORY ¢ / <br /> ivas Tank tested? Yes Failed precision test 7 Yes No <br /> was a repair made to the tank system? Yes No 1f yes, <br /> what waa repaired? <br /> Was repair done under irepection7 Yea <br /> No Were soil saaptes analyzed? Yes No TX iPH- TP11- - bIED <br /> Type of failure/discharge catastrophic o,g-t"m leakag overfill untuiown other: r'-A h-A;., <br /> ;V. REMOVAL HISTORY (ATTACH INSPECTION REPCRT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> �jBT : Average Annua <br /> Soil Sanples l Precipitation ka 14 10-25 <br /> Recetv Yes No Depth to Ground Yater - Ref/Year <br /> Cn-Site Yells) Yes o NuoSar 4 Type Irr Dom Pub S Score S Score S Score <br /> ft C 10 pts C 9 pts c 5 pts <br /> tI _Gf t; 0 if 0 if <br /> Distance to Will from Tank O if condition R condition <br /> R condi cion R is met <br /> E is met E is met E <br /> V. Site Feature - Leaching P(Itmtiat Analysis >100 51_100 5 25-50\1 <br /> INiniaua Depth to groundwater from the Soil Sanpte (feet) Present <br /> �O None Unknown <br /> Fractures in subsurface (applies to foothills or al areas) 9 10-25 xxxxxxx 26-40\2 <br /> 'l xxxxxx <10� <br /> Average Annual Precipitation (inches) p <br /> Man-Made which elmigration <br /> None Ukro+a Present <br /> of teachato (I.e., septic systems, watrwells, s) <br /> At least More than <br /> Unique site features: Recharge area, coarse soil. nearbywelts. 7otx nearby xxxNome one one <br /> Io , . ra - 38 <br /> COLUMN TOTALS»TOTAL POINTS 40 is or less <br /> Sacple Result: (a T X CR E) RANGE OF TOTAL POINTS 49 pts or once 41 Ga pts P <br /> a T X E a T X E NA\3 <br /> MAXIMA ALLCIMLE a-T-X-E LEVELS (PPM) 1 50 50I 50 .3 .3 1. 1- 10 <br /> GASOLINE 1000 100 <br /> Sample Result: 1000 100 <br /> �f d,ay�D MAXI?" ALLLW.9LE TPN LEVELS (PPM) DIESEL 10,000 <br /> h, do not Complete the leaching potential <br /> �++If docamented soil and/or ground water contamination to Dresent, ground <br /> FOOTNOTES: analysis. (i.e., site is currently on LOT Contamination List ffoornoLt uasertable. <br /> water.) <br /> \1 if depth is > 5 ft. and < 25 ft.,store are 0 points. It dap (gasoline) or 100 ppm (diesel). <br /> \2 if precipitation is > 40 inches, <br /> \3 levels for S= are not applicable at a TPN concencratlon of 10 ppm <br /> Vt. STAFF RECCIWE.VDATICM/COHCLUSICM <br /> 1. Are STX i E or TPH Concentrations M ls 'Yes No <br /> 2. Recommend Stte Closure les <br /> oQatar to Si to Mitigation for Evaluation <br /> VII. REVIEW EVALUATICN - TO SE COWPLETED /SENIOR <br /> CCNCJR WITH STAFF QECpgENOAT tC% FCR CLOSURE YES NO {REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> / DATE CLOSURE LETTER RAILED <br /> - DATE REFERRED / - <br /> NAME Of <br /> EVALUATOR <br /> EH Z3 a0 CUGTVKSHT)\5/90 <br />