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"W�rPUBLIC HEALTH SERVICES/SVIRONHWAL WilPFEWS tax <br /> j* YORKSNEET FOR SITE CLOSIAIE EVALUATION DATE <br /> 'NAME OF FACILITY SSIEEPS CODE <br /> ADDRESS , TANK IDN a <br /> TANK SIZE ,Vc5OD IFUEL, TYPE So ` <br /> [I. GENERAL SITE HISTORY <br /> Is permit Erent?H No Permit a - Facility status Code Doc.SoiL/GW Cast Yes Na <br /> Number of Tanks at facility Age of Tanks(if awitabts) Type of Tank SteeL Fbrgl Sngt Duet <br /> III. TANK HISTORY <br /> Was Tank tasted? rim No Failed precision test ? Yes No if yrs, giw dste<s) ! ! <br /> Was a repair made to the tank system? Yes Ha If yrs, what was repairrd? <br /> was repair darn under inspection? Yes Mal Were soil "Miss enalyzed? Yes Na BT7LE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic lang-term leakageawrfitl tnimasas other: <br /> IV. REMOVAL HISTORY (ATTAM INSPECTION METE OET ILSC13L VpjW,,WCHIXr1 POTENTIAL ANALYSIS) <br /> Soft Somptes Received Yes Na Dapth to Gmnd dater qb Ref/Year p/v Average Amort Precipitation A* 14 10-25 <br /> On-Site Weit(s) Yes No Number i Type Irrtv Dam Pub <br /> S Score S Score S Score <br /> Distance to Welts) from Tankft; JC <br /> (2—f ft C 10 pts C" 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R' condition <br /> V. Site Feature - Leaching PatentiaL Analysis E is met E is met E is not <br /> Minimum Depth to groundwater from the Sail Saspte Cfeet) `:"� >100 31-100 25-50\1 <br /> Fractures in subsurface (applies to faothitts or mountain areas) None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx 410 9 10-25 xxxxxxx 26-40\2 <br /> Man-Nede conduits which increase wrticat migration <br /> of leachate Cf.e., septic systems, water weds, ponds) None Uniao►n Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At Least More than <br /> xxxxxx morn ane are <br /> COLUMN TOTALS»>TOTAi. POINTS b + �S . <br /> le Lt: (11 T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 40 pts or less <br /> 151 MAXIMUM ALLOWABLE B-T-x-E LEVELS (PPiI) t 5Q SO 50 .3 I.3 1. 1 XA13 <br /> Sampte Result: GASOLINE 1000 100 10 <br /> -23 10 p� MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> �J I TPN DIESEL. 10,000 1000 100 <br /> FOOTNOTES: If documented soft and/or grasd water contamination is present, do not comptete the leaching patential <br /> anatysie. Ci.e., site is currrntty an UGr Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth 4=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for STXEE are not appiicabte at a TPH concentration of 10 ppm (gesotina) or 100 ppm Cdiaset). <br /> VI. STAFF 2ECOPIMATION/CONCLUSION <br /> I. Are BTX i E or TPH Concentrations > Atlowobte Lewis 'Yes No d 1� � <br /> 2. Recoamumd Site Ctaaure Yes No if Yes, Refer to Site Mitigation for Evaluation s ^-" V <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/ IOR go � J r <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSMIYES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED ! ! iDATE CLOSURE LETTER MAILED ! ! <br /> NAME OF a <br /> EVALUATOR <br /> IN 23 80 (UffrWKSHT)\5/90 <br />