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$Ali <br /> I� d UGST WOOKSHEEOR SITE ICELOSUREIEVALUAATI TN DIVISION AT710-,;i5-,Po <br /> M <br /> ITY <br /> EPS CODE <br /> ANK <br /> L TYPE e! <br /> 11. GENERAL SITE MIST Y G� <br /> s permit current? a o ermit E - <br /> acility Status Code q oc.Soil/GW Cont a <br /> r of Tanks at facility s2 pe of Tanks(if available) <br /> . yp*'of Tank tact brill t <br /> 111. TANK NISTORY Dual <br /> Jas Tank testedn a o ailed precision test ? as o <br /> 11 f yea, give dat*(s) <br /> a repair made to the tank system? a No f yes. what wasrepairod7 <br /> s repair done under inspection? as o re soil samples analysed?tea o iXE PN-G PM-D EDB <br /> ype of facture/discharge stastrophfc brig-term leakage erfill cher: <br /> IV. REMOVAL NISTORY (ATTACH 1 ION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACNIMG POTENTIAL ANALYSIS) <br /> it Samples Received as o epth to Ground Water of/Year <br /> verage Annual Precipitation s 4 0.25 <br /> Site Wett(s) es o r i Type 1rr an ub <br /> istancs to Wella) from Tank S core S core S core <br /> f t; _,__f t; ,T__f t C 0 pts C p is C a <br /> 0 if 0 if0 f PCs <br /> Site Feature - Leaching Potential Analysis R ondition R ondition R ondition <br /> E is met E is met E I.mot <br /> fnimmas Depth to groundwater from the Salt Sample (feet)��(} , <br /> . too ,.,� zs.sD�, <br /> ractura in subsurface (applies to foothilts or mountain areas) <br /> Mone tklkrlatl resent <br /> verage Annual Precipitation (inches) 470 <br /> 9 10-25 26-40.0 <br /> -Mede conduits which increase vertical migration <br /> f leachate (f.*., septic systems, water Notts, ponds) <br /> None Unknown resent <br /> ique site features: Recharge area, coarse soil, nearby wells. <br /> At least to than <br /> uxxxx Mone aye one <br /> CMAAGI TOTALS>»TOTAL POINTSSaW + <br /> to R <br /> e <br /> s <br /> ult; (a T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 4a pts 40 pts or less <br /> MAXIMUM ALLOWABB T x ELE R-T-X-E LEVELS (PPM) 1 50 50 50 NA13 <br /> Lompte Result: <br /> NID iNtM ALLOWABLE TPN LEVELS (PPM) INE 1000 100 10 <br /> TPN IESEL 10,000 1000 100 <br /> OOTNOTES: 8"If documented soft and/or ground water contamination is present, do not caplete the leaching potential <br /> anslysis. (i.e., site is currently on UGT contamination List for soft or ground water.) <br /> 11 If depth is > S ft. and < 25 ft., scar* 0 points. it depth «5 it.. do not use table. <br /> L2 It precipitation is > 40 inches, scar* 0 points. <br /> 13 Levels for BTXLE are not appticabte at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF REMN EWDATION/CONcWS(ON / �Q-�Q <br /> 1. Are BTX Z E or TPN Concentrations > Allowable Levels Yes To <br /> 2- Racormwd Site Closure es If Yes, Refer to Sits Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> KATEREFEUMED <br /> H STAFF RECONMEMDAT1OM FOR CLOSURE ES EFERRED TO SITE M171GAT1ON FOR EVALUATION ES <br /> / ATE CLOSURE LETTER MAILED <br /> EN 23 80 (UGTWKSNT)\5190 <br />