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JCAOIi[ -11TY PUBLIC REALM SERVICES/ENVIROWENTAL HEI - DIVISION <br /> T WORKSHEET FOR SITE CLOSURE EVALUATION DATE /,0 ... <br /> LAJ+ !T7.73a- I <br /> Penait N Facility Status Code Doc.Soit/GY Cont Yes-41 No <br /> illy �'f Age of Tsnks(if available) Type of Tank Steel FbrgL Sngi1 Dwl <br /> Failed precision test ? Yes No I If yes, give dates) <br /> to the tank system as No If yes, 1hat was repa,red? <br /> jaw under frspecrion? Yes No Yore soil samples IM-1 BmI TPH-G ITPN-0+ Pb/£06 <br /> ture/diacharge catastrophic tang-tors teakagel joverfiltj junknownj other: <br /> IML NISfOKY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LFACNING POTENTIAL ANALYStS) <br /> left SampLet Received Iles IM1. Depth to Ground Yater Ref/Year Average Annual Precipitation As 14 10-25 <br /> pn-Site Yetl(s) Yes No Number i Type Irr 10=1 I Pub <br /> S Score S Scare S Score <br /> Distance to Yett(s) from Tank ft; ft; ft C 1C pts C 9 pts C 5 <br /> O if 0 if 0 <br /> R condition R condition R condition <br /> V. Site Feature - Leeching Potential Analysis E is met E is met is met <br /> Minimum Depth to groundwater from the Soit Sample (feet) 10-41— 2,100 i I51-10 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain arses) I one, (Present <br /> Average Annual Precipitation (inch ) XXX)= <10 I 9 t0-25 xxxxxxx 26-40\2 <br /> Man-Mede conduits which inereese verticat migration !�-� 5 <br /> of leachate (i.e., septic system, water wells, ponds) Nana Unknown Present <br /> Unique site features: Recharge arae, coarse soil, nearby weds. At lust More then <br /> None ane ane <br /> COLLM TOTALS»>TOTAL POINTS + 4. a <br /> Sample Result: <9 T X OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 - 48 pts 40 pts or less <br /> 1411 AJ D B TX E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-£ LEVELS (PPM) t 50 50 50 .3 .3 t.1 1. NA\3 <br /> Sample Result: GASOLINE 1000 t00 10 <br /> j� MAXIMtM ALLOWABLE TPH LEVELS (PPM) <br /> YY TPH DIESEL 1 10,000 1o0 100 <br /> FOOTNOTES: **"If doaamntsd soil and/or ground wets r ca-t—nation is present, do not complete the Leeching potential <br /> analysis. (i.e., site is currently an UGT Contamination list for Boit or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. if depth ­5 ft., do not use table. <br /> \2 if precipitation is > 40 inches, score 0 points. <br /> \3 Levels for STXW are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel)).( <br /> VI. STAFF RECOMMENDATION/CONCLUSION 55A <br /> 1. Are BTX b E or TPH.Concentratiaa > ARloeabte Levels *Yes N0 ' <br /> Z. Recommend Site Closure Yes No tf Yes, Refer to site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COWU70 SY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOHNWATION FOR CLOSURE YES1 NO REFERRED TO SITE X(TIGiTION-F& EVALUATI YES NO <br /> DATE REFERRED 1 / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> L'YA JATOR <br /> REI a 80 (UG1WXSHT)\5/90 <br /> w <br />