Laserfiche WebLink
i . <br /> SAH JOAOUtH CCUI�'IFILIC HEALTH SER'llCcSlEHVtACNMENTAL HEALTH SIGN <br /> I• UG§V RXSHEET FOR 517E CLOSURE EVALUATIGN <br /> AtE (, <br /> SEEPS CODE' Z ZZC� <br /> UEOACILITY ��� p�t-pAHK IO Coy � t �` t•I SCS UEL TYPE <br /> Il. GENEtAL SITE HISTORY ww <br /> Is permit currenc7 es <br /> a remit acitity•Scatus Code 3 oe.5 l/GV Cont es o <br /> anter of Tanks at facility ge •of Tanks(Lf available) r ype of rank" reel 5rg( ngl Dual <br /> Ill. YANK HISTORY <br /> �s Tank tested? es a ailed precision test 7 es a' If yes, give <br /> as a repair made to the tank system? es No f yes, whac was repaired? 5 <br /> Was repair done under inspection? es o - ere sail samples analyzed? es o TXE PH-G PH-0 b/1018 <br /> ype of failure/discharge atastrophI long-term Leakage verfitl known thee: <br /> IV. AEY.OVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT.DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ail Samples Received es a ep!to Ground Water of/Year S �6 verage Arcual Precipitation 4 0-25 <br /> -Site WeEICs) esr pe Ire om ub <br /> S core S core S core <br /> istance to Wetl(s) from Tank ft: ft:' ft C 0 pts C pts C pts <br /> 0 if 0 if0 f <br /> R ondition R candition R ondition <br /> Site Feature - Leaching Potential Analysis E is me[ E is meta E s met <br /> inim= Depth to groundwater from the Soil Sample (feet} >100 1-t00.'. s 25-50\1 <br /> ractures in subsurface (applies to foathEIts or mountain areas) ,Q None Unknaim resenc <br /> verage Annual Precipitation (inches) xxxx <10 9 10-Z54 xxxxxx 25-40\2 <br /> an-Made conduits whirh incree vertical migration <br /> None Unknown resent <br /> se <br /> f Leachate (i.e., ptic syst , water welts, ponds) -s <br /> pique site features: Recharge area, coarse soil, neaeby wells. At least are than <br /> xxxx Hone Y one one <br /> COLUMN TOTALS>>>TOTAL POINTS �Ca * <br /> ample Result: (B T X OR Ey RANGE. OF TOTAL POINTS 9 pts 'or more 41 - 48 pts' 40.pts or less <br /> Q� w2 31-?m B T X EB T x -E- . <br /> r: •i/ppM �� N a HAxIMLlI ALLCWA6LE B-T-x-E LEVELS (PPM) ) 50 50 50 ). HA\3 <br /> ample Result: ASCLINE. 1000 100 10 <br /> qAXIMUM ALLOWABLE TPH LEVELS (PFK) <br /> �� PPS TPH IESEL 10,°000 1000 100 <br /> OOINOTES: 'w*If documented sail and/or ground water contamination is present, do not complete the leaching potential <br /> E analysis. (i.e., site is currently on UGT Contamination Listfor sail or ground water.) <br /> I \1 If depth is > 5 ft. and < 25 It., scare Vpoints- If depth <=5 ft., do .not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel).. <br /> VI.. STAFF RECCFWENDATICN/CCNCLUSION <br /> 1. Are 3TX E or'TPH Concentrations > At Levels hes o' <br /> 2. Recommerd Site Closure es o If Yes, Refer to Site Hitigation' for.Evatuaticn <br /> ill. REVIEW EVALUATION - TO 3E CCMPLETED 3Y A.SUPE2VISOR/SENIOR <br /> oNCUR utTH STAFF RECC++r.ENDAT[OH FOR CLOSURE SES 0 I PERKED TO SiTE`!{IT[GAitOH FOR EvALUATICN ES O <br /> )ATE REFERRED / / 7/ AIE CLOSURE LETTEA MAILED <br /> TAME OF <br /> ;VALUATOR �� a ' <br /> LH 23 80 (UG%'KSHT)\5/90 T <br /> 1 �1 <br />