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( SAH 10AGUIN CMM1,y_,a 'ELIC HEALTH SERVICES/ENVIRONMENTAL I�HEALTH '?SIGN <br /> UG 32KSHEET FOR SITE CLOSURE EVALUATION <br /> OF FACILITYART- <br /> I? 1q3 VIC/G <br /> I'} TANK LD 1 A�g- _9 3 l <br /> ' TANK SIZE FUEL TYPE ' <br /> GENERAL 5I E HI RY <br /> is permit current? Yes o Pe tt # Facility Status Code'; ! Doc•Soil/Gf� Cont Yes Na <br /> Nunber of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Duct <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test T les No If yes,lgive dates) <br /> uas a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes ^ No BTXE TPH-& TPH-D Pb/ED8 <br /> Type of faiture/discharge catastrophic tong-term leakage averfiLL unknwwn other: <br /> IV. R£MOM HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> 0/ • !� Avarage Annual Precipitation A' 14 11.0-25 <br /> r Soil Samples Received Yes No Depth to Ground Vater O Ref/Year , <br /> �. <br /> On-Site VlCs) Yes No Hr Type trr Dam Ptyb �f <br /> S Score S Scare S Scare <br /> ft C ,pts C 5 pts <br /> Distance to Well(s) from Tank ft, ftp 10'IC 9- -- 0 111, . 0 1.pts 0 if <br /> R condition R condition R condition <br /> E is meE is metV. Site Feature - Leaching Potential Analysis E ismet i <br /> Minimum Depth to groundwater from the Soil Sample (feet) <br /> >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> None Unknown Present <br /> Average Annual Precipitation (inches) xxzxxx <10 9 10-25 xxxxxxx 2b-40\2 <br /> d <br /> Man-Made conduits which increase vertical migration H�ne Unknown Present <br /> of leachate (i.e., septic systems, nater wells, ponds) <br /> At least More than <br /> Unique site features: Recharge area, Coarse soft, nearby wells. xxxxxx None one one <br /> l <br /> # COLUMN TOTALS»>TOTAL POINTS 0/ 1 <br /> Sample Result: (B�OR E) <br /> RANGE OF TOTAL POINTS 44 pts or more 41 - 48 pts 40 pts or teas <br /> Al( No B T X E ' B T X E <br /> e C7�� ri^' MAXIMtrN ALLOIiJ�eLE B-T-X-tc i.EVELS (PPM} 1 50 50 50 ' .3 .3 1. 1. �\3 <br /> GASOLINE 1000 100 10 <br /> Sample Result: 4. <br /> MU <br /> MAXIM ALLOWABLE TPH LEVELS (PPM) 100 <br /> � o TPH DIESEL 10,000 a 1000 <br /> pre <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is sent, do not complete the leaching potential <br /> analysis. (i.a., site is currently on UGT Contaminatdon 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 /> > <br /> \2 If precipitation is 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicabte at a TPH concentration 10 ppm (gasotine) or 100 ppm (diesel <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPN Concentrations > ALL able Levels *Yes No <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISORISENIOR I� <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE 14ITIGAT.ION FOR EVALUATION YES NO <br /> DATE REFERRED ! ! DATE CLOSURE LETTER MAILED ! ! <br /> NAME OF <br /> EVALUATORS <br /> If <br /> EH 23 80 (UGTWKSHT)\5/90 �' <br />