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SAH :CACUIN CCUNTi LIC HEALTH SERVICES/EYVIRCHMEYTAL HEALTH Di- ICN <br /> I. UGST CSHEET FOR SITE CLOSURE SVALUATICN AtE <br /> AME Of FACILITY ,, / EEPS CCOE <br /> AnoaEssl 2835 NQV OYl h 'YANK to x �� <br /> tANX SIZE b UEL TYPE <br /> If. GENERAL SITE HISTORY <br /> Is permit current? les o ermit x aei(icy Stacus Code oe.So'(/GW Cont es a <br /> -qurber of tanks at facilicy 1ge of Tanks(if available) ype of Tank tee? beg? ngi V'0--T7 <br /> .I. TANK HISTORY <br /> I1ns Tank tested? es o ailed precision test es o If yes, give date(s) <br /> 4as a repair made to the tank system? es No V f yes, what was repaired7 <br /> as repair done under inspectiont es ere sail samples analyzed? es o TXE PN-G PH-0 b/E08 1 <br /> -Type of failure/discharge atastrophic Long-term leakageverfill I -known (her: <br />�. REMOVAL HISTORY (ATTACH IHSPF TION REF-CRT FCR SITE OETAILS/COLLECT DATA FCR LEACHING POTENTIAL ANALYSIS) <br /> SoiL Samples Received i es V o epth to Ground 'later JQ/ of/Year ;b?G verage Annual Precipitation = 4 0-25 <br /> :--Site WeLL(S) es o umber b Type !rr on ub <br /> S core S care S core <br /> 'istance to Well(s) from Tank ft; ft; ft C 0 pts C PCs C pts <br /> O if 0 if 0 f <br /> R a-diticn R endition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> !inimun Oepth to groundwater from the Soil Sample (feet)��- � i >100 I I-100 I 25-50\1 <br /> rac:ures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> average Arnual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxx 26-40\2 <br /> tan-Made conduits which increase vertical migration <br /> i_:f teachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> nique site features: Recharge area, coarse soil, nearby wells. At teas, are than <br /> xxxx None one one <br /> CCLUM TOTALS—TOTAL POINTS ,. a I L <br />_.:mole Result: (3 T X CR E) RANGE OF TOTAL POINTS F9 pts or more I 41 - 48 pts 40 pts or less <br /> 3 T X E B JT X E <br /> MAX11". ALLCUA3LE 3-T-X•E LEVELS (PPM) 1 50 50 50 3 . 1. 1. NA\3 <br /> Pie Result,- rIAES�EL <br /> 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH 10,000 1000 10O <br /> ';NOTES: ***If docunented soil and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or graund 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 37XSE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> ;rAFF RECCf4¢NOATICN/CCNCLUSIO9 <br /> Are 3TX 9, E or TPH Concentrations > ALLow le Levels Yes o <br /> Recommend Site Closure eso If Yes, Refer to Site Mitigation for Evaluation <br /> REVIE'J EVALUATICR - TO SE COMPLETED RY A SL'PERVISCR/SENICR <br /> 4CJR WITH STAFF RECC14HENOATICN FCR CLOSURE �ES LEFERRED TO SITE HITIGAiICN FOR EVALUAi[CH �ES � 0 I <br /> .IE REFERRED " / / -� ATE CLOSURE LETTER MAILED <br />"ME <br /> 'ALOF <br /> LUA1CR <br /> 1 23 80 (UCT.'KSHT)\5/90 <br />