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SAM .OACUM CC:4TT Pf HEALTH SEx'/ICES/ERVIACRME4TAL HEALTH DIV( ! <br /> UGST :L ET FCR SITE CLOSURE EVALUATICN ATE I 12- 'i V:/ <br /> UE CF FACILITY I d� . / q. :EEPS �. <br /> NX 512E �13C <br /> UEL TYPE <br /> :E4 E."Al S <br /> permit currenty res a ermit N aeility Status Cade oe.Soil/Gu Conc es o <br /> mer of ranks at facility �1ge of ranks(if available) ype of Tank Leel �Fhrgl ngl Dual <br /> TANX HISTCRT <br /> s tank les:ed7 es o ailed Pr_t ision test 1 Iles o if yes, give da te(s) / / <br /> a repair mode Co the lark system? es 40 f yes, what was repaired? <br /> epair done :xder iruoection? 14es o Jere SOIL samples an4lyted7 Hes a TXE PH-G I Px•D b/EDB <br /> .e of faitureldischarge Lr acastrophic long-cern leakage verf ill n cher: <br /> EHCVAL 4ISTCRY (ATTACH INSPECTION REPCRT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> I Samples .Received Fes o epth to GreLnd 'lacer G of/Year l .. average Annual Precipitation a pG 0-25 <br /> i <br /> Site Vett(s) lyes I o iunber i Typel Irr poo b <br /> S core Score S core <br /> tante to Vell(s) froo Tank ft; ft; ft C 0 PCs C 7 pts C pts <br /> 0 if 0 if 0 <br /> d onditim R corclition R cndi cion <br /> Site feature - Leaching Potentlal Analysis E is Dec E is met E s met <br /> iimFa Oepth to grounduater fran the Soil Saeple (feet) I >100I - 1-100 <br /> c-ures in sut=rface (applies to foothills or Datncain areas) NoneI C) Unknown present <br /> •rage Annual Precipitation (inches) <10 I 9 10-25 �=X=x 26-4O\Z <br /> •made conduits which increase vertical migration <br /> leachate (i.e., septic System, water wells, ponds) xme G Unknown resent <br /> 4:e site features: Recharge area, coarse sail, nearby wells. At leas: ore than <br /> XXX More we ane <br /> COLUMN TOTALS»>TOTAL POINTS ✓ =' ' 1 <br /> le Result: (3 T X OR E) RANGE OF TOTAL POINTS 9 Pts or more / 61 48 Pts'. GO PCs or Less <br /> Q L•01 <br /> j 3L.a 1Xa L•J3 <br /> 3 T X E l a T X E <br /> �' L•�y HAMALLCVL <br /> AM 3-T•X•E EVELS (PPM) 1 50 50 50 .3 .3 t. I. NA\3 <br /> ,", <br /> Pie xesulc: IICANE 1000 100 10 <br /> ,4AX)M)N ALLOWABLE iPH LEVELS (i PN) - <br /> px I fE5cl 10,000 1000 100 <br /> INOTES: ^if doeunented soil and/or grand water contamination is Present, do rgcc cmnplete the 'Leaching Potential <br /> (/ �ajJpyvl ariLysis. Cf.*., site Is currently on UGT Contamination List for' FiAl or-gresnd water.) <br /> ` II \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <:i ft., do not use [able. . <br /> \2 If preeipi Cation is > 60 inches, score 0 points. <br /> \3 levels for 3TXEc are roc applicable at a TPH concentration of 10 ppo (gasoline) or 100 ppm (dieseU. <br /> TAFF RECCMIENOAT ICN/CCNCLUS ICN <br /> Are 3TX I E or TPM Concentrations > Allowable Levels Tes o <br /> 2=.: erd Site Closure If Yes, Refer to Site Mitigation for Evaluation <br /> IEVIEY EVALUATICH . TO 3E COMPLETED 3Y A SUPEAVISCR/SENICR <br /> AC'R WITH STAFF xECCHM.E 40AT(CN FCR CLOSURE ESI 0 I pEFERRED TO SITE YITICATfCH FOR EVALUATION HES I 0 <br /> c REFEAREO I / / PATE CLOSURE LETTER PAVED <br /> r <br /> .c <br /> %LUAICR <br /> 23 10 (UCT:YSMT)\5/90 <br />