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ssior_.. <br /> 'CLClR [ EVALUATIow OA TE Jo 2� <br /> IT so, m-am-tir SWEEPS COOS 'Z <br /> ADDRESS 2 S (� �Q TANK ID it - D <br /> TANK SIZE } FUEL TYPE <br /> 1I. GENERAL SITE HISTORY <br /> *** <br /> is permit current? Yes No Permit 0 Facility Status Code _tOoc.Soi!/W Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) ype of Tank SteelFbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No VfFaited precision test AYesj o If yes, give dates) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes Were soil samples analyzed? Yes No BTXE TPN-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill I unknown I other: <br /> IV. REMOVAL HISTORY (ATTACH INSPICTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received YesI V1 No Depth to Ground Water 10, Ref/Year r ; S�O Average Annual Precipitation A= 14 10-25 <br /> On-Site WeLL(S) Yes o Number 3 Type U!� rr Dam Pub <br /> S _Score S Score S Score <br /> Distance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minimun Depth to groundwater from the Soil Sample (feet) 10'_q :(p1p >100 51-100 O 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) 0 None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None 9 Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxx(x'xx None _I one one <br /> COLUMN TOTALS> >TOTAL POINTS I v + + O = ,.!2✓ <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> B� <br /> 5U PPM `�� I`1 B T X E B JT X E <br /> go SO get. MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. /. NA\3 <br /> —n <br /> Sample Result: GASOLINE 1000 100 10 <br /> ZSPP�^ d� Li TP Jt MAXIMUM ALLOWABLE TPN LEVELS (PPM) DIESEL 10,000 1000 100 <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 /> \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 STXSE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> Vi. STAFF RECOMMENDATION/CONCLUSION Q 0-111 Pro <br /> � W��sbY15 0.0 �oss <br /> 1. Are BTX & E or TPH Concentrations > ALL able levels *Yes up a <br /> No n/�V � �'(� <br /> 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evatuation � 'QiLC I� <br /> InCWJ.La� <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A 'SUP£RVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED /�/ ( (P / �'� DATE CLOSURE LETTER MAILED <br /> NAME OF t <br /> EVALUATOR <br /> EH 23 30 (UGTWKSHT)\5/90 <br />