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SAH JCAOUIN COUNTYIHEET <br /> C,:HEALTH SERVICES/ENVIRONMEYTAL HEALTH at ON <br /> j UGST 'FOR SITE CLOSURE =VALUATICH ... DATE <br /> NAME 3F FACILITY Y rC S'.IE=PS CDOE (, <br /> :CCRSSSI C� 1 Ir ` ?AHK ID C 1'Q 3 I g <br /> "AHK S i ZE� FUEL TYPE �� i k �^ 0 .� <br />,. GENERAL SITE HISrCRY D Pe—moved <br /> :.. <br /> its permit current7 Yes No Permit 2 - � Facility Status Code] Doe.soiLjGW Cont Yes No <br /> Number of Tanks at facility1 ' ,3 Age of Tanks(if available) Type of Tank Steel Fbrgl Sngt 0ual <br /> 4 ;. TANK HISTORY I <br /> 4vas Tanis tested? Yes No Failed precision test T les No If yes, give date(s) <br />']Was a repair made to the tank system? Yes No 1� If3,yes, what was repaired? <br />, Was repair done under inspection? Yes Ho hers soil samples analyzed? Yesl 6al BTXE I IT ITPN-0 Pb/ED8 } <br /> !Type of failure/discharge catastrophic tong-tsrm leakage overfill unknown I other: <br /> i <br />:V. RE.iCVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE.DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Gr" WatetY Ref/Year �; Average Arw=L Precipitation A-114 10-25 <br /> I <br /> On-Site Wells) Yes Na Number & Type Err Dom IPub <br /> S Score 5 IScore S Scare <br /> Distance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if r <br /> R condition R condition R :' condition <br /> V. Site Feature - Leaching Potential Analysis , E is met "e is met E is net <br /> IMinimu:m Depth to groundwater from the Sail Sample (feet) >1Q0 5]-100 r l 25-50\1 <br /> Fractures in subsurface (applies to foathiLts or n6imta'in areas) None I Unkrmown �Present <br /> Average Arcual Precipitation (inches) XXXXXX <ID 9 10-aS XXXY,= Zb-40\2 <br /> Man-made conduits which increase vertical migratioi <br /> of leachate (i.e., septic systems, water wells, pangs) Norte Unknown Present <br /> F <br /> Unique site features: Recharge area, coarse soil;.nenrby wells. At least More than <br /> {F. xxxxzx None 9 one one <br /> COLUMN TOTALS»>TOrAL POINTS ,•; <br /> b �G <br /> Sample Result: (B T X OR E) RANGE]OF-TOTAL POINTS 49 pts ar more 41 - 4a pts 40 pts or less <br /> ° <br /> 31 T I X E B JT X E <br /> KIALLOWLE 13-T-X-E'LEVELS (PPM) 1 50 50 50 .3 .3 HA13 <br /> Sample Result: i[:z GASOLINE 1000 100 10 <br /> MAXIMUM ALLONABLE TPH LEVELS.(PPM) <br /> TPH ?r OIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil ard/ar gro6�d riat"er contamination is present, do not complete the teaching potential <br /> anaLysis. (i.e., site ii currently on UCT Contamination List for soft or ground water.) <br /> \1 if depth is > 5 ft. and < Z5 ft., score 0 points. If depth 4*5 ft., do not use table- Y <br /> \2 If precipitation is > 40 inches, scone 0 points. <br /> \3 Levels for 8TXAE are not applicableIat a TAN concentration of 110 PM (yygaso{(ne) or 100 ppo (diesel]. <br /> LI <br /> VI. STAFF RECCHMENDATICN/COHCLUSICN <br /> f !' <br /> 1. are 3TX A E or TPN Concentrations > Allowable Levets *Yes No roo ' <br /> Z. Recommend Site Closure Yes INC If Yes, Rater to Site Mitigation for Evaluation �� <br /> ti. <br /> VIZ. REVIEW EVALUATION - To aE CCMPLFTED 47 A SUPERVESCR/SEHICR 1 <br /> C:.HG:R 'JIrH STAFF RECCMMENDATICH FOR CLOSURE TES1 Np REFE3RED TO SITE NITIGATICU FOR EVALUATION YES HO <br /> DATE REFERRED / / �2 DATE 'CLCSI7RE LETTER ?TAILED <br /> NAME 3F s" <br /> EVALUATCst <br /> EH 23 30 (IIGTWKSHT)\5/9Q <br />