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^� rY�YiY MGA&IM acKVI.� IM MMITAL NEALTN DIVISION <br /> U0 -`VKSNEET FOR SITE CLOSIAM EVALUATION —.�O DATE <br /> W% OF FACILITY % <br /> C <br /> n00RE35 �_ Com, � TANK ID 017, c <br /> TANK SIZE UQ I FUEL TYPE die <br /> . GENERAL SfIt MISMY <br /> Is permit awrrsM7 Tem1 No Permit S - Facility status Code 6�pZ– Doc.Soit/GW Cont Yes No <br /> Nuaber of Tanks at facility Ape of TW*sCff avaftabte) Type of Tank Steel Fbrgt Sngt oust <br /> I. TANK NISTORY <br /> Was Tank tasted? Yes No Fasted precision test t Yes No If yes, give dates) <br /> Ws a repair made to the taNc systasA Yea No if yes, what was repairedt <br /> Was repir done under inspection? Yes No Were soft samples analysed? Yes Mo STXE TPN-0 TP11-0 PWM <br /> ;Type of failure/dfschmrpe catastrophic long-term teskaGe overfill Ir*nown others <br /> �. REMOVAL NISTORT CATTACN INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACNING POTENTIAL ANALYSIS) <br /> soft Samples Received Yes Mo Depth to ground Water s'a Ref/Year 1,?&: Average Annual Precipitation A• 1t 10-25 <br /> 1On-Site Welt(s) Yes Mo Nuober i Type Irr 10=1 I►cab <br /> S score s Scare S Score <br /> Distance to Watl(s) from Tank (oi_ft; tt; ft C 10 pts C 9 pts C S pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V. site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Ninimum Depth to groundwater from the Soft Sample (feet)So-19CY' >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothftIs or mountain areas) j D None unknown Present <br /> Average Annual Precipitation (inches) xxxxxx 00 9 10-25 xmu= 26-4M <br /> Man-Meds conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water welts, ponds) None Unknown 5 Present <br /> Unique site features: Recharge area, coarse soft, nearby wells. © At least Nore than <br /> xxxxxx None l one one <br /> COLIM TOTALS>»TOTAL POINTS ) • • 40 -3 ?'- <br /> Sample Result: M T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> s Xz 'W1 <br /> ow v a8• oQN 1 T X E g T X E <br /> I MAXINLM ALLVAULE R•T-X-E LEVELS (PPN) 1 50 50 50 .3 .3 1. 1. NA�3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMM ALLOYADLE TPR LEVELS (PPM) <br /> y A TPN D DIESEL 10,000 1000 Ile100 <br /> FOOTNOTES: "*If documented soft and/or grand water contamination is present, do not complete the teach sat <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. end < 25 ft., score 0 points. If depth "S ft., do not usa table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for IT)= an not oWticeble at a TPN concentration of 10 ppm (gasoline) or 100 ppm (dfesat). <br /> vi. STAFF RECOMN;IDATION/CONCUISION <br /> 1. Are STX i E or TPR Concentrations > Allowable twats "Yes 11101 1 <br /> 2. Racemmmfd site Ctosun Yes No If Yes, Refer to site Nitigation for Evaluation <br /> vII. REVIEW EVALUATION - TO a CONLETED BY A wPElntt <br /> COMM WITN STAFF RECOSENDATION FOR CLOSURE YES VO REFERRED TO SITE NITICATION FOR EVALUATION YES <br /> GATE REFERRED ! DATE CLE LETTER NAILED / ! <br /> NAME OF O �/Q <br /> EVALUATOR V <br /> EN 23 30 CUGTWKSNT)TAO <br />