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LTH SERVICES/ENVIRONMENTAL HEALTH DIVISION DATE <br /> FOR SITE CLOSURE EVALUATION <br /> SWEEPS CODE j <br /> R <br /> Viggo: <br /> �' TANK [D # <br /> 11. GENERAL SITE HISTORY Q <br /> Is permit current? Yes Na Permit # - Facility Status Cade ( Doc.Soi L/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) 4G'i✓'Z Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Fai Led precision test ? Yes No If yes, give ate(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yesl Mn RTXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage ­.'+iEll unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water Ref/Year <br /> Average Annual Precipitation A= 14 10-25 <br /> On-Site WeLL(s) Yes No Number & Type Irr Dam Pub S Score S Score S Score <br /> Distance to WeLL(s) from Tank ft; ft; ft GC 10 pts CC 9fpts CC 5f pts <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Ana Lysis E is met E is met E is met <br /> Minimum Depth to groundwater frau She Soil Sample (feetft— P31 I <br /> >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> ' O <br /> Average Annual Precipitation (inches) xxxxxX <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase verticaL migration (} None Unknown I Present <br /> of Leachate (i.e., septic systems, water wells, ponds) <br /> At Least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. XXXXXX Nona one one <br /> COLUMN LS»>TOTAL POINTS C 4P3 <br /> Sample Result: IS T X OR E) <br /> RANGE OF TOTAL POINTS 49 pts ar more 41 - 48 pts 40 pts or Less <br /> / N A)ll,_� B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> sanple Resul GASOLINE 1000 100 10 <br /> /I N D �"/9A>fl �e MAxiMUM ALLOWABLE TPH LEVELS (PPM) <br /> 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 Contamination List for soil 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 /> \2 If precipitation is > 40 inches, score0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & EfCtosure <br /> centrations > Allowable Levels -Yes No X <br /> 2. Recommend SYes No *If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED eY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATIONIYES NO <br /> DATE REFERRED / / DATECLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />