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II. GENERAL SITE HISTORY <br />permit current? @So efmit #acility Status Code I 1Doc.SoiL/GW Cont es o <br />mnber of Tanks at facility ge of Tank(if available) IType of Tank teet I 1Fbrg( I ngl Dual <br />III. TANK HISTORY <br />as Tank tested? <br />es <br />o <br />ailed precision test ? <br />es <br />I <br />o <br />verage Annual Precipitation = �4 0-25 <br />If yes, give date(s) <br />Jas a repair made to the tank system? es No <br />f yes, what was repaired7 <br />as repair done under inspection? es o <br />ere soil samples analyzed7 es o I TXE PH -G PH -0 b/EDB <br />Type of failure/discharge <br />C <br />atastrophic tong -term teakage <br />verfitL <br />0 <br />if 0 <br />ther: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received <br />es <br />o <br />epth to Ground Water <br />/ A <br />of/Year <br />; - <br />verage Annual Precipitation = �4 0-25 <br />-Site Welts) es o umber & 7ype Irr om ub <br />S core <br />S <br />core S core <br />istance to Well(s) from Tank ft; ft; ft C 0 pts <br />C <br />pts C pts <br />0 if <br />0 <br />if 0 <br />R ondition <br />R <br />condition R ndition <br />Site Feature - Leaching Potential Analysis Et <br />E <br />is mat met <br />inimumm Depth to groundwater from the Soil Sample (feet) >100 <br />Jr <br />10ML <br />1-1PVT ( 25-50_\1 <br />Fractures in subsurface (applies to foothills or, tai areas None <br />resent <br />Average Annual Precipitation (inches)< <br />10-25 xxxx 26-40\2 <br />an -Made conduits which incre se v n g on <br />f leachate (i.e., septic ate wells, ponds) None <br />Unknown resent <br />nique site fetur ar ah, , coarse soil, or els- <br />At least ore than <br />[Muncipa[=>20 0 ft; s - 500 ft; irr/agricuttural=Q sent) xxxx None <br />one one <br />10-1 <br />COLUMN TOTALS>>>TOTAL POINTS * <br />+ <br />ample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS t9 pts or more <br />41 - 48 pts 40 pts or less <br />®® <br />B <br />7 X <br />B <br />X E <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 <br />JE <br />50 50 50 <br />.3 <br />kT 1, 1. NA13 <br />ample Result: <br />LINE 1000 <br />100 10 <br />AXIMUM ALLOWABLE TPH LEVELS (PPM) <br />rIESEL <br />1000 100 <br />10,000 <br />OOTNOTES: --if documented soil and/or ground water contamination is present, do not complete the teaching potential <br />analysis. (i.e., site is currently on UGT Contamination List for soil 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 BTX&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX & E or TPM Concentrations > Allowable Levels Yes o <br />2. Recommend Site Closure 6s 1 o 1 If Yes, Refer to Site Mitigation for Evaluation <br />VI1 <br />REVIEW EVALUAT IUN - lU tit GUMPLETt0 UT A NUFtKV1aUK/<.CiUJ CX1 K <br />:ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION <br />)ATE REFERRED I / / AT CLOSURE LETTER MAILED <br />LAME OF <br />:VALUATOR I ,� <br />EH 23 80 (UGTWKSHT)\5/94 <br />