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RECEIVED <br /> MS N .OACUIN�L L[C XEALTH SER`lICES/EWtRCHNEHTAL HEALTH! ISICN <br /> I•• U XSHEET FOR SITE CLOSURE EVALUATION i ATE <br /> nME OF FAC II ITT .'E EPS <br /> CODE <br /> e.cN a_„N-o .222 <br /> 00REi5 ANK 10 41 - .0'Z.2 a <br /> c< <br /> AHK SIZE Shfl UEL TYPE etz4e/bot <br /> If. GENERAL SITE HISTORY T� <br /> Is permit current7 es o ermit Y - acility st1Latus Code 3 oc.59.i 1/GW Corrl es I MQ f <br /> �unber of Tanks at facility) pge of Tanks((f available) IUti / �ype of Tank �teel brg( Hyl Oual <br /> III. TANK HISTORY 1 .G <br /> as Tank tested? eso ailed precision test 7 es o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es o Jere soft samples analyzed? es o 1XE PH•G IT <br /> PH-0 0/ED8 <br /> ype of failurei d ischarge atastrophic ling-terve leakage verfill Hawn [her. <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received eso epth to Ground Yater of/Tear s e( verage Arcual Precipitation 4 Q-ZS <br /> •site vell(s) es o umber L Type trr am b <br /> S core S core s core <br /> istance to Wells) from Tank ft; ft; ft C 0 pts C pts C Pts <br /> 0 f 0 if 0 f <br /> R ondition It ondition R ordttion <br /> Site Feature - Leaching Potential Analysis E 's met E is met E s met <br /> iniauv Depth to groundwater from the Soft Sample (feet) >100 1-100 s Z5-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) �Q Vone Unknown resent <br /> vcrage Arcual Precipitation (itches) zzzz <10 9 10-25 szzszs 26-40\2 <br /> an-Made conduits wh_jr.�e-qLe vertical migration <br /> 1 leachate (i.e., septic syst Nater wells, ponds) Hone Unknown S resent <br /> pique site features: Recharge area, coarse soft, nearby wells. At least are than <br /> zzza None 9 one one <br /> COLUMN TOTALS»>TOTAL POINTS /Q O 38' <br /> ample Result: IS T XOOutR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> �w �13 'FM X: B T X E <br /> T .d/(�K FI NQ NAXIMLH ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. HA\3 <br /> ample Result: SOU HE 1000 TOO 10 <br /> '�41paM TPH 1ftH ALLOWABLE TPN LEVELS (DPN) IESEL 1 10,000 1000 100 <br /> COTNOtES: •..11 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 soft or grovel 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 paints. <br /> \3 Levels for STXSE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECCWENOAT I ON/CCNCLUS ION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Tes V o <br /> 2. Recc=erd Site Closure n a If Yes, Refer to Site Mitigation for Evaluation <br />,it. REVIEW EVALUATION - TO BE CC14PLETED BY A SUPERVISOR/SENIOR <br /> •OHCUR WITH STAFF RECCNMEHDATION FOR CLOSURE ES I FERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED -7 AJE CLOSURE LETTER MAILED t y <br /> 1AME Of <br /> :VALUATCR <br /> EH 23 80 (UGTCXSHT)\5/90 <br />