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up <br />nau /f•.N It C' nN1\ITV Nim rn uru ru nrnurnrn muvrnn.u.r..r .. .er .. .._ e••.•.. •.... <br />li. GENERAL SITE HISTORY <br />*w <br />o permit current? es o ermit 0 - acility Status Code l'l oc.Soil/GW Cont es o L <br />tuber of Tanks at facility ( ge of Tanks(if available) I UJ,/ ype of Tank teet Fbrgl 1SngL I "Dual <br />111. TANK HISTORY <br />Jas Tank tested? <br />es <br />0 <br />o <br />ailed precision test ? <br />es <br />o <br />if <br />yes, give dates) <br />; <br />as a repair made to the tank system? Yes No <br />f yes, what was repaired? <br />es <br />as repair done under inspection? <br />es go ere soil samples analyzed? <br />es <br />umber & Type <br />o <br />1rr <br />TXE <br />om <br />PH -G <br />ub <br />PH -D <br />b/EDB <br />Type of failure/discharge <br />atastrophic long-term leakage1. <br />verfill <br />known <br />r <br />ther: <br />IV. REMOVAL HISTORY (ATTACH INSPCCTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soft Samples Received <br />es <br />0 <br />o <br />EFERRED TO SITE MITIGATION FOR EVALUATION <br />epth to Ground Water <br />of/Year <br />verage Annual Precipitation <br />N= <br />4 <br />0-25 <br />Site Wells) <br />es <br />o <br />umber & Type <br />1rr <br />om <br />ub <br />S <br />C <br />0 <br />Score <br />10 pts <br />if <br />S <br />C <br />0 <br />Score <br />9 pts <br />if <br />S <br />C <br />0 <br />core <br />5 pts <br />if <br />istance to WeII(a) from Tank,6t, <br />ft; ft; ft <br />R <br />E <br />condition <br />is met <br />R <br />E <br />condition <br />is met <br />R <br />E <br />ondition <br />s met <br />Site Feature - Leaching Potential Analysis <br />inimum Depth to groundwater from the Soil Sample (feet) 1 5 <br />1-100 <br />25-501 <br />>100 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />None <br />f <br />Unknown <br />resent <br />Average Annual Precipitation (inches) <br />KXXXXX <br />00 <br />9 <br />10-25 <br />xxxxxxx <br />26-40_\2 <br />an -Made conduits which increase vertical migration <br />C' <br />f leachate (i.e., septic systems, water wells, ponds) <br />None <br />1 <br />resent <br />pique site features: Recharge area, coarse soil, nearby wells. <br />-Unknown <br />C <br />At least <br />4ore than <br />xxxxx <br />None <br />I <br />one <br />one <br />COLUMN TOTALS» >TOTAL POINTS <br />+ <br />tL <br />+/ <br />Sample Result: (B T X OR E) RANGE OF TOTAL POINTS <br />e- ec l-,, i1m*`, Q`eGlSlA <br />9 pts or more <br />41 - 48 pts <br />40 pts or less <br />B <br />1 T <br />X <br />E <br />B JT <br />X <br />I -E <br />Om N•J' <br />Lo MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />1 <br />50 <br />50 <br />50 <br />.3 .3 <br />1. <br />1. <br />NA)3 <br />ample Result: ASOLINE <br />1000 <br />100 <br />10 <br />AXIMUM ALLOWABLE TPN LEVELS (PPM) <br />10,000 <br />1000 <br />100 <br />TPN lESEL <br />FOOTNOTES: ***If documented 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 ground water.) <br />L 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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />V1. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX 8 E or TPN Concentratio s > Allowable Levels Yeso V <br />2. Recommend Site Closure es o If Yes, Refe to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SiNIOR <br />CONCUR WITH STAFF,RECOMMENDATION <br />FOR CLOSURE VES1 <br />0 <br />EFERRED TO SITE MITIGATION FOR EVALUATION <br />ES <br />0 <br />ATE REFERRED <br />I <br />ATE CLOSURE LETTER MAILED <br />AME OF <br />VALUATOR <br />�/ l <br />W - <br />EH 15 BU (UGTWKSHT)\5/90 <br />