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r_ PUBLIC HEALTH SERVICES/ENVIROMMEHTAL HEALTH DIVISION <br /> ti <br /> RXSHEET FOR SITE CtOSilRE EVALUATION <br /> �^ Stine CODE <br /> UO� <br /> TAHf( ID iTW � f <br /> FUEL TYPE ! <br /> 'FL S TE HISTORY "• <br /> r <br /> e it current? Yes No Permit N - Facility Status Code Doc.Soil/G61 Cant Yes Na <br /> oder of Tanks at facility <br /> Age of Tanks(if available) (] Type of Tank Steel Fbrgl Sngl Dual <br /> 1TANX HISTORY <br /> ins Tank tested? Yes No Failed precision test ? Yes Hp if yes, give date(s) <br /> 1 <br /> t Vas a repair made to the tank system? Yes Na If yes, what was repaired? <br /> vas repair done under inspection? Yes No were snit samples analyzed? fes Na STXE TPH-G TPH-4 Pb/EDB <br /> Type of failure/discharge catastrophic long-term Leakage overfill unkno+as other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soi! Samples Received Yes No Depth to Ground water -' Ref/ioar g- Average Annual Precipitation As 14 10-25 <br /> On-Site vel L(s) Yes No Muaber L Type !rr Dam Pub <br /> S Score S Score S Store <br /> Distance to uell(s) frm Tank ft• ft; ft '! C 10 pts C 9 pts C 5 pts <br /> o if 9 if 0 if <br /> R conditioni R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met 'E is met <br /> ' <br /> MinionDepth to groundwater from the Soil Sample (feet) 'i >1o0 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) I NoneUnknowri Present <br /> Average Annual Precipitation (inches) i xxxxxx <10 9 10-25 :1 xxxxxxx 26-40\2 <br /> Man-bade conduits which increase vertical migration <br /> of Leachate (i.e., septic systems, water wells, pords) Mane Unknatiai;. Present <br /> unique site features: Recharge area, coarse soil, nearby wells. At least Bore than <br /> xxxxxx Aare one ane <br /> COLUMN TOTALS»>TOTAL POINTS , ?f�/ � � ' ` <br /> Sapie Res V_t (BST X OR ra) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts, ;,� 40 pts or Less <br /> B T I X I EB T X E <br /> MAXIMUM ALLOWABLE 3-T-X-6 LEVELS (PPM) 1 50 SO 50 .3 .3 1- t- s Mll\3 <br /> Sample Result: GASOLINE loco 100 10 <br /> MAXIMIM ALLOWABLE TP11 LEVELS (PPM) <br /> /8-0 A4161 TPH DIESEL10,000 =ICM <br /> oIca <br /> jFOOTNOTES: *"If documented soil and/or ground water contamination is present, do not coeQlets thellesching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., scare 0 points, if depth <=9 ft., do not use table. <br /> l \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for 3TX&E are not applicable at a TPN cbncentration of 10 ppm (gasoline) or too ppar: (diesel). <br /> V.I. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX b E or TPS Concentrations > Allowable Levels 'Yes Mo <br /> f!1Tf'�7'(nD� �r <br /> 2. Recommend site Closure Yes NO j< If fes, Ref" to site, Mitigation for Evaluation <br /> VII. REVIN EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR VITH STAFF RECCWMNDATICN FOR CLOSURE YES MO REFERRED TO SITE MITIGATION FOR EVALUATION YESI 1NO <br /> DATE REFERRED ! / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR) <br /> EH 23 80 CUGTUXSHT)\5/90 <br />