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CA Al InAM ITU 'MTV 01101 Tr UCAI TU CC0%1TrCC/CLI%1T0r 1uC TA1 (1T•" TLI TAT1110Tr111 <br />11 -CO- CTTC UTCTnOV <br />*** <br />s permit current? Yes No Permit Facility Status Code Dcc.SoiL/GW ConItYes7N-1 <br />umber of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br />reulr uTcmTk.3 ov - <br />Was Tank tested? Yes <br />No <br />Depth to Ground Water !Ref/Year Average Annual Precipitation <br />Failed precision test ? Yes <br />On -Site We(L(s) Yes No Number & Type <br />No <br />If yes, give date(s) <br />S <br />C <br />0 <br />R <br />E <br />Was a repair made to the tank system? Yes <br />No If yes, what was repaired?I <br />Was repair done under inspection? Yes <br />S <br />C <br />0 <br />R <br />E <br />No Were soil samples analyzed? Yes No <br />BTXEI <br />TPH-G <br />TPH-OI <br />Pb/EDB <br />Type of failure/discharge <br />catastrophic <br />long-term Leakage) overfill <br />25-50\1 <br />unknown! other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received Yes <br />No <br />Depth to Ground Water !Ref/Year Average Annual Precipitation <br />A= 14 10-25 <br />On -Site We(L(s) Yes No Number & Type <br />Irr Doml <br />Pub <br />S <br />C <br />0 <br />R <br />E <br />Score <br />10 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />9 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />5 pts <br />if <br />condition <br />is met <br />Distance to WeLL(s) from Tank ft; ft; ft <br />V. Site Feature - Leaching Potential Analysis <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />51-100 <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />Present <br />Average Annual Precipitation (inches) <br />xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxx. <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />Present <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />xxxxxx <br />None <br />At Least <br />one <br />More than <br />one <br />COLUMN TOTALS» >TOTAL POINTS <br />+ <br />+ <br />I= <br />Sample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />! 41 - 48 pts <br />40 pts or less <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />I <br />11 50 50I 50 <br />.3 .3 <br />1. 1. <br />i <br />NA\3 <br />Sample Result: <br />TPH <br />GASOLINE <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />DIESEL <br />1000 <br />100 <br />10 <br />1 10,000 <br />1000 <br />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 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 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 & E or TPH Concentrations > Allowable Levels *Yes No <br />2. Recommend Site Closure Yes No 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 CLOSUREIYES NO !REFERRED TO SITE MITIGATION FOR EVALUATION YES INO <br />ATE REFERRED / / DATE CLOSURE LETTER MAILED <br />AME OF <br />VALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />