Laserfiche WebLink
,4.I <br /> SAH dL'p�_ hN COUNTY PUBLIC HEALTH SERVICWENVIRONMEN+r- HEALTH DIVISION ATE 9 — <br /> I <br /> — —�Q <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVAL'UA. <br /> WEEP�LDN <br /> E �p�.� <br /> E OF FACILITY Cj p - •S b]_Q t <br /> TANK f O'� r <br /> DRESS � r <br /> ANK SIZE / 0�() UEL TYPE <br /> 11, GENERAL SITE UISTDR <br /> a <br /> acility Status Code oe.5011/GW Cont es o <br /> is permit current? as o rmit M <br /> unbar of Tanks at facility <br /> pe of Tart[cs(If aveltable) ype of TnNc teal brill ngl Dual <br /> Ill. TANK HISTORY P7 <br /> o a{ted pr test 7 es o If yes, give date(s) �oZlaoZ /a I- <br /> as Tank tested? as f r—ee <br /> No f yes, khat was repaired? MrQQSe6 CL)Y� <br /> as a repair made to the tank system? as %E PH•G PN•D b/EDB <br /> as repair done under Inspection? as o ere soil swpLes analyied? as o T <br /> Type of failure/discharge atestrophlc <br /> long-term leakage verfilt sown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSP TION REPORT FOR SITE RETAILS/COLLECT DATA FON LEACHING POTENTIAL ANALYSIS) <br /> a th to Ground Water 116 of/Year ; verage Arrwat Precipitation 4 C-25 <br /> of l Sarnplea Received as e P <br /> -Site Wel (s) as o utter A,Type irr om ub S care S core S core <br /> ft C <br /> i) pts C pts C pts <br /> istnnce to Wel1(a) from Tarot 1t; ft; 0 if 0 if 0 if and{tion R ondition <br /> R ortdttion R <br /> 1, <br /> Site Feature Leaching Potential Analysis V E is mat E is ma[ E is met 1-100 25-50, <br /> s100 <br /> inirmr.m Depth to groundwater from the soil Swrple (Icot)�.a� Unknown resent <br /> f None <br /> ractures In subsurface (applies to foathitls or amountnin areas) V xxxx <10 9 10-25 xxxxxx 25.401? <br /> verage Annual Precipitation (inches) <br /> an Made conduits which increase vertical migration None ! Unknown resent <br /> f leachate (i.e., septic systemas, Water wolfs, ponds) i At least ore than <br /> q one <br /> iquz site features: Recharge area, coarse soil, nearby trails• xxxx None <br /> COLLISN TOTALS>y>TOTAL POINTS <br /> arrpte Result: (B T % OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> 7i'a✓��c1 A- ` ,3 'q'?, 0 T x E T X E NAL <br /> r 4f 71,L-1, 5/x� � MAXIMUM ALLOWABLE a-T•X'E LEVELS (PPM) 1 50 50 50 �3 .3 1. 1. <br /> 50L[NE 1000 <br /> 100 10 <br /> ample Result: 1MUH ALLOWABLE TPH LEVELS (PPM) T00 <br /> / IESEL 10,000 1000 <br /> ^r�&GIL.�!) TPH caiptential <br /> DOINOTES: •+'If documented soil and/or ground water eanta UCTiUnationtI'!spresent, do not for sollloreleaching the � <br /> ground water-) <br /> analysis. (i.e., site is currently <br /> 11 If depth is > 5 ft. and < 25 ft., score 0 points. if depth «5 ft., do not use table. <br /> y2 If precipitation is > 40 inches, scare 0 points. PP"m asotine) or 160 ppm (diesel). <br /> 13 Levels for STUE are not applicable at a TPN concentration of 10 (g I <br /> LA. <br /> VI. STAFF REGOMMENDAT(ON/CONCLUSION -_13 )-L0 <br /> 1. Are BTX L E or TPH Concentrations > AtLowabte Levels 4es a t/ <br /> 2. Reconiaend Site Closure as o V If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EYALUA7ICL TO BE COMPLETED BY A SUPERVISOR <br /> ITE MITIGAI[OM FOR EVALUATION ES 0 <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES <br /> U EFERNED TD S <br /> ATE REFERRED <br /> ATE CLOSURE LETTER MAILED <br /> / / <br /> iAME OF <br /> 'VALUATOR <br /> Eu 23 80 (UGIWKSNT)15/40 <br />