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-•�• -.-.�... vrvw.. -vara• wa:A&SM WALi11 <br /> W--'SET FOR SITE CLOSURE EVALUATION DATE / <br /> of FACILITY �^ CODE <br /> ADDRESS 0-. Qr� TAMC ID #L3 ct <br /> TANK SIZE FML TYPEOKI <br /> fi(,�,L <br /> _. 0h�RAt LITE Y <br /> Is permit current? Yes No Permit g - 03AA3 facility Status Coda Doe.soit/W Cont Yes No <br /> 'N+aber of Tanks at facility -+go of Tanks(If avaitmle) l type of Tank Stoat Fbrgl Srgl Oust <br /> I. TANK NISTORY <br /> Use Tank tested( Yes 1,4Nol failed precision test 7 Yes No V If yes, give dots(*) <br /> Was a repair made to the tank systa4 Yes No If yes, what was repaired? <br /> ;Yes repair dons under inspection( Yes No Were soil samples analyzed? Yes No STXE TPN-G TPN-0 Pb/M <br /> Type of failure/dIseharga cstastrophic long-tan leakage overfill unknown other: <br /> J. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to 0round voter d Ref/Ysar STO ; Average Annual Precipitation As 14 10-25 <br /> On-Sits Vett(s) Yea No Njdw i type Irr Gam ►ub <br /> S Sew* S score s scare <br /> Distance to WettM from Tank ,;_-,,oft; ft; 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 - Leeching Potential Analysis E is not E is get E Is met <br /> Minimum Depth to groundwater frog the Solt SaMple (feet)$O--, c. 4 30100 51-100 25.50\1 <br /> Fractures in suborface (applies to foothills or santsin areas) None Unknown Present <br /> Average Annual Precipitation (inches) xxz:ook 410 9 10-25 (naxuook 26-60\2 <br /> Man-Made conduits which increase vortical migration <br /> of teschate (f.e., septic systems, water walls, ponds) None Unknown present <br /> unique site features: Recharge area, coarse soft, nearby wits. Q At lent Nore than <br /> xxxx:ok None ( one one <br /> COL M TOTALV3n TOTAL POINTS 1 * 1 F 1 / 1- 3 Y <br /> Semple Results (g T X OR E) RANGE OF TOTAL POINTS 69 pts or more 61 - 49 pts 60 pts or less <br /> fvD. 11 T I x I E g IT X E <br /> MAXIMUM ALLOWAI S-T-X-E LEVELS (PPR) 1 SO SO 50 .3 .3 1. 1. NAV <br /> Sample RES-TM <br /> . CASOLIHE 1000 100 10 <br /> All MAXIM MALLONA/LETwLEVELS (PPM) DIESEL 10,000 1000 100 <br /> FOOTNOTES: **-If documented soft w&or ground motor contamination is present, do not complote the teaching potential <br /> analysis. (f.*., site is currently an My Contamination List for soft or ground water.) <br /> \1 If depth is 30 S ft. and < 25 ft., score 0 points. If depth 4.5 ft., do not use table. <br /> \2 If precipitation is 30 60 inches, score 0 points. <br /> V Levels for NTXLE are not applfcable at a TPN concentration of 10 ppm (gasoline) or 100 ppm Wesel). <br /> VI. STAFF RECMMMTION/CONCWSION <br /> 1. Are STX i E or TPR Concentrations 30 Allowable Levels -Yes No <br /> 2. tocoamrd site Ctoaure Yes No If Teo, Refer to site Nfttgation for Evaluation <br /> Qr05 S �'bi.� C��•+�?4K7Ay <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUAERVISORMNIOR jrV <br /> COMM WITH STAFF REwwwATtON FOR CLOstRE YEs qNO1 REFERRED TO SITE NITIWTION FOR fVALUATIONr YES NO <br /> DATE REFERRED / / DATE CL06URE LETTER MAILED <br /> � OF I <br /> EVALUATOR <br /> EN 23 80 CUGTWKSHT)\5/90 <br />