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SUTY�AN JOA( NH SE ICES/ENVIRONMENTAL HE� DIVISION <br /> I. <br /> LOST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY �6 EEPS CODE <br /> DDRESS LA <br /> IT ANK SIZE I IFUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit k acility Status Code ".Soil/GW Cont es 70 <br /> umber of Tanks at facility Be of Tanks(if available) IType of Tank �teel I IFbrgl I pngl LD <br /> uall <br /> I11. TANK HISTORY I <br /> 'as Tank tested? as o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? IYes No I 11f yes, What was repaired? <br /> ns repair done under inspection? as o ere soil samples analyzed? es !o T%E PH-G PH-D b/EDO <br /> Type of failure/discharge atastrophic long-term leakage verfill mknown1 10 ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .oil Samples Received Ifes I o epth to Ground Water I of/Year verage Annual Precipitation = 4 10-25 <br /> Dr-Site Wells) IYes o umber 8 Type Irr I om I ub <br /> S 3core S Score S core <br /> istance to Well(s) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> .0 if 0 if 0 'f <br /> R ondition R condition R ondition <br /> V. Site feature . Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) U None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 Kxxxxxx 26-40\2 <br /> nn-Made conduits which increase vertical migration e <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> 7nique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxxx None one S one <br /> COLUMN TOTALS»>TOTAI POINTS 1161 + + <br /> ample Result: IS T X OR E) RANGE OF TOTAL POINTS F9 pts or more 41 48 pts 40 pts or less <br /> B T X E B T I % E <br /> MAXIMUM ALLOWABLE B•T-%-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> -ample Result: ASOLTNE 1000 100 10 <br /> A%IMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently on 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, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels FT o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFE RRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED / / <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />