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Feb 26 01 08: 55a Sig' 'cure Properties Dura 510 562 5437 p. 1 <br /> ."..."."� <br /> ro: p�ENw — <br /> el- 15 �ssP�✓ <br /> DEPT: - --`'~ <br /> Department of Health Services <br /> 0%: �pL, t --- Division of Drinking Water and Environmental Management <br /> MTBE VULNERABILITY ASSESSMENT FOP"M <br /> �x-550ca-a'610 <br /> plete a separate farm for each active source serving your water system. <br /> Return to your LPA by April 30,2001. <br /> Water System Name: �-- <br /> Water System No.: <br /> Primary Station Code: <br /> Source Name: - <br /> Check the appropriate box. Ground,vater Source ❑ Surface Water Source <br /> STEP 1: MTBE DATA <br /> Data collected to date: Data Results <br /> ❑ Show a detection of MTBE Date(s)of sample(s) <br /> Do NOT show a detection of MTBE Result(s) ug/L <br /> STEP 2: POSSIBLE CONTAMINATING ACTIVITIES (PCA's) IN ZONE OF INFLUENCE <br /> Mark all boxes far activities that have occurred/are occurring in the Zone of Influence for this source. <br /> The Zone of Influence is defined for each type of source below. <br /> Surface Water Source Groundwater Source <br /> Zone of Influence: 400' from reservoir banks or Zone of Influence: 1,500' for porous media aquifer <br /> primary stream boundaries 2,250' for fractured rock aquifer <br /> 200' from tributaries <br /> 1 <br /> Gas Stations(existing or historic) Gas Stations (existing or historic) <br /> Petroleum p.rocessin gisforageTtransfer areas A ttiraubile repa,r and/or body shops <br /> Petroleum pipelines Petroleum processing/storage/transfer areas <br /> Petroleum pipelines <br /> Fleet/truck bus terminals Fleet/truck/bus terminals <br /> Airports-Maintenance/fueling areas Airports-Maintenance/fueling areas <br /> Railroad Yards-Maintenance/fueling areas Railroad Yards-Maintenance/fueling areas <br /> Military installations Military installations <br /> Utility stations-Maintenance areas Utility stations-Maintenance areas <br /> Motor pools Motor pools <br /> Illegal/unauthorized dumping Illegaiiunauthorized dumping <br /> Known petrochemical contaminant plume Known petrochemical contaminant plume <br /> Leaking underground petroleum storage tanks Leaking underground petroleum storage tanks <br /> Underground petroleum storage tanks(not leaking) Underground petroleum storage tanks(not leaking) <br /> Above ground petroleum storage tanks Above ground petroleum storage tanks <br /> Freeways/Highways/Roads/Streets Junk/scrap/salvage yards <br /> Railroads <br /> Motorcraft:recreation <br /> Storm drain discharge points <br />