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SUI 10AGUINL:u*rY PUBLIC HEALTH SERVIC-S/ENVIRCNMEVTAL HEA:. OIVISION <br /> 1. UGST WORKSHEET FOR SITE :OSLIRE EVALUATION DATE! <br /> NAME OF FACILITY I 019 L, D {n Fl/ , /4 75" el S ISIEZ01 SEI O• <br /> ADORESSI 3 7 -S T1 ,��r�(�( (TANK lD 3 . q <br /> TANK SIZE! 1d,106 (FUEL TYPE!D i LI yL^t-• I stO GrL P( { P. <br /> II. GENERAL SITE HISTORY I <br /> Is Permit current?IYmI NoI l )emit 3 - !Facility Status Coder / IDoc.Sait/d ConclYes INa <br /> Numer of Tanks at facility Age of Tardts(if avaitable) (Type of Tanklsteetl IFbrgLl ISngtl Oual <br /> III. TANK HISTORY L.:.•..n 3 rl- _38 C'rK,;V. f <br /> Was Tank tested? Yes Na !Failed precision test ?lYesl lNo) If Yes, give date(s7 V40/3/ I6; <br /> Was a repair made to the tank systadllYes I Mol IIf yea, what vas repaired? l'"111_� f"p";l✓4L"le- '_p444A <br /> Was repair done under inspectiarll Teal INoi !Were soil saeoles ana Lyzed7lYesl INoI BTKEI ITPH-Gl ITPH-Dl IPEE08I <br /> Type of failure/discharge! I catastrophic I ILang-term Leakage! Io.,fitLI lurearo ! lather: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTICH REPORT FDR SITE DETAILS/COLL_cCT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Saaeles ReceivdlYesl No !Depth to Ground Water! IRef/Year !Average Annual Precipitatianl Asll4 10-75 <br /> Y"I No INueber b Type lirrl local IPWI <br /> On-Site Wel l(s)I <br /> S Score "a Scor: S Score <br /> Distance to Wel (s) from Tank ft; ft; C 10 pts - 9 pts C 5 pts <br /> 0 if 0 if D if <br /> R condition R condition R condition <br /> V. site Feature - Leaching PotentiaL Analysis is met _ is met E is met <br /> Minimm Oepth to gm, ater from the SaiL -aamole (feetl _ l I -100 I X51-100 I i 25-50\1 <br /> i <br /> Fractures in subsurface (applies to foothills or mow Iain areas) I None I I wwww I Present <br /> Average Annual Precipitation (inches) nuua7cl 410 ! 9 l 10-25 j=poOal 25-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, Water Valls, ponds) ` Naro I UMmmn (Present <br /> Unique site features: Recharge area, coarse soil, nearby Watts. I I At Least IMore than <br /> roma More, ane one <br /> MUM M iOTAI.S>TOTAL POINTS i ; I • I I� <br /> Savoie ResuLt: IS T X OR E) RANGE OF TOTAL POINTS 49 pts or mora ! 41 48 pts ! 40 pcs or less <br /> MXIM N ALLOYABLE B-T-X-E LEVELS (PPM) BI SOI 50I 50 .3 I.3 1.i 1. I NA\3 <br /> S le Result: GASOLINE 1000 ! 100 i 10 <br /> (MAXI" ALLWABLE TPN LNELS (PPM) <br /> PH D DIEsa lo,ow 113111 1DO <br /> FOOTNOTES: —If documented soil and/or grand Water contamination is present, do nat replete the Leeching potential <br /> P3�1300 aMC aerlysis. (i.e., site is currattlY on � d UQT inscion List for sail or granwatar.) <br /> � /r \1 If depth is > 5 ft. ad < S ft., score 0 points. If depth ca5 it., do not use table. <br /> 5�P n2 If precipitation is > 40 inehas, spore 0 mints. <br /> \3 Leveis for STXl4E are not applicable at a TPH concentration of IIIppm (gasalins) or 1130 ppm (diesei). <br /> Vt. STAFF RECOMMENDATION/CONCLIMION S -- <br /> P-3 -rB 3 .0 1`pp vv- <br /> 1. Are BTX d E or TPN Concentrations > Allowable Levels I-Yesl INa! ISP4 <br /> L=4 - Wt T13 E -. Q. C <br /> 2. Recommend Site Closure l Yesl 1"I �-If Yes, Refer to Site Mitigation for Eveluatiml I run ip� <br /> VII. REVIEW EVALUATION - TO 3E CCMPL=-TED BY A SUPERVISOR/SENIOR JJ <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSLtEITESI IND' (REFERRED TO SITE MITIGATION FOR EVALUATTcmj YES! (Nal I i <br /> DATE REFERREI / / (DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 SO (UGTWKSHT)\5/90 <br />