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I' UGIT VORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY SkdS CODE <br /> ADDRESS <br /> TANK IOM G <br /> TANK SIZE � :'fJ FUEL TYPE <br /> It. GENERAL SITE HISTORY <br /> Is permit current? Yes No P*reit t Faaitity Status Code Doc.Soil/GY Cant Yes No <br /> Number of Tanks at fseility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Owl <br /> III. TANK HISTORY <br /> Use Tuck tested? Yes No Failed precision test T Yes No 1 If yes, give date(s) <br /> Was a repair mmde to the tank systm? Yes NO if yes, what was repeird7 <br /> Ws repair done under inspection Yea No Yore soil suptes aralyzed7 Yes No sTXE TPN-G TP11-0 Pb/EDM <br /> Type of faiture/discharge catastrophic long term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAIIS/COLLECT DATA FOR LEACRING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Groundalter Ref/Yaar Avers" Annual Precipitation A=114 10-25 <br /> On-Site Welt(s) Yes Mo Niaber L Type Irr tkr Il Pub <br /> S Seo" S Score S Seo" <br /> Distance to Yeats) from Tank ft; ft; ft C 10 pts C 9 pts C S pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential. Analysis E is meet E is mat E is met <br /> Minimmm Depth to groundwater from the Soil Saepte (feet) �S, 31-100 51-100 25-50\1 <br /> fractures in wAm rfwa Cappties to foothills or mountain cress) Nano Unknown Present <br /> Average Annual Precipitation Cind:es) :0000a 410 9 10-25 x:on000k 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of teeehate (i.e., septic systsmt, water watts, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse salt, nearby welts. At least More than <br /> xxxOok None ane one <br /> COLUMN TOTALS»>TOTAL POINTS + + s <br /> SBaaplNGE: (B T X OR E) RAOF TOTAL POINTS 49 pts or sere 41 48 pts 40 pts or less <br /> �r j v ' � B T X E s JT X E <br /> Y k[ •L C''G'r" MAXIMUM ALLOWABLE i-T-X-E LEVELS CPP") 1 SO SO SO .3 .3 1. 1. � MA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE IPM LEVELS CPPM) <br /> k•'D L j r� TpM- DIESEL 10,000 1000 100 <br /> FOOTNOTES: —tf documented soft and/or ground water commination is present, do not caW*te the teaching potential <br /> analysis. (I.e., site is c rrentty an UCT Contamination List for soil or ground water.) <br /> \1 If depth is > S ft. and 4 25 ft., sew a 0 points. If depth �m5 ft., do not use table. <br /> \2 if precipitation is > 40 indas, score 0 points. <br /> \3 Levels for $I= we not applicable at a TPN concentration of 10 ppm Cgasotine) or 100 ppm (diesel). <br /> Vt. STAFF RECOMMEWATtON/Ca iXION <br /> 1. Are BTX i E or TPM Conant"tions > Allowable Levels *Yes 1"1 1 <br /> 2. Reeaafmand Site Closure Yes No if Yea, Refer to Site Mitigation for Evaluation <br /> Vtt. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> C=X WITH STAFF 2ECM00ATION FOR MOMURE YES NO REFERRED TO SITE MITIGATION FGR EYALUATtON YES NO <br /> DATE aEFERREO / / DATE CLosm MYER M tum <br /> NAME OF <br /> EVALUATOR <br /> EH 23 m (UGT%KSNT)\5/90 <br />