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/ SAH ]OACUiH COUH'' '3LIC HEALTH SERVICES/ENVIRONMENTALHEALTH-""'Isl Q <br /> I UC iRXSHEET FOR SITE CLOSURE EVALUATION GATE L <br /> NAMZ Of FACILITY (� SWEEPS C" 6 <br /> 1AODRZ S5 J14 0. 14 Krr - £ TAMC IO f 3 —Q <br /> ITANX SIZE) FUEL TYPE g <br /> [I. CE4ERAL SITE HISTORY <br /> �Is permit current? Yes No Pe it # - Facility Status Code Doc-Soil/GW Cont Yes Ho <br /> Humber of Tanks at facility Age of Tanks(if available) a i Type of Tank Ste'[ Fbrgl Sng{ Dual <br /> 3 <br /> III. TANK 4ISTORY <br /> 4vas Tank tested? Yes ' No Failed precision test 7 Yes Ho If yes,l give dal <br /> 1Vas a repair made to the Lank system? Yes No if yes, what was repaired? <br /> Was repair done under inspection? Yes No lWera soil samples analyzed? YesHoa aTXE TPH-G TPH-0 Pb/E08 <br /> Type of failure/discharge catastrophic long-term leakage overfill unk�rtexrt other: <br /> IV. RF-40VAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) - <br /> • Average Arr�ual Precipitatior14 <br /> Soil Samples Received Yes No Depth to Ground Water Ref/Year , <br /> On-Site WeW s.) Yes No Number & Type Irr Dom Pub S score S Score S ft• ft C 10'Ipts C 9 pts C Distance to We{[(s) from Tank ft% ifs 0 if O R condition R condition R v. Site Feature - Leaching Potential Analysis E is,1metE is met E <br /> Minimum Depth to groundwater from the Soil Sample (feet) X100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills.ar moesttain areas} <br /> None Q Unknown Present <br /> Average AnnuaL Precipitation (incites) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> 'S- <br /> Man-Made conduits which increase vertical migration gone Present <br /> of Leachate (i.e., septic systems, water wells, ponds) <br /> At least More than <br /> unique site features: Recharge area, coarse soil, nearby wells. xx� mom one one <br /> 3 (0 l <br /> -COLUMN TOTALS»:TOTAL POINTS . If * s 'f <br /> Sample�Rresult: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or mors is 40 pts or less <br /> It- J MAXIMUM ALLOWABLE S-T-X-E LEVELS (PPM) 1 50 50 .3 .3 ]. 1. NA) <br /> Samp{e Result: <br /> GASOLINE 1000 Joe 10 <br /> 3TPH70MAXIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL 10,000 1000 100 <br /> ` s <br /> FOOTNOTES: ***if documented soil and/or ground water contamination is present <br /> do not complete tate leaching potential <br /> analysis, (i.@., site is currently on UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft., and < 25 ft., $cora 0 points. It depth'�5 ft , do not use tabic. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels far BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diese{)• h€ <br /> VI. STAFF RECOMMENDATION/CONCLUSION wtU � <br /> 1. Are 3TX & E or TPH Concentrations > Allowable Levels��Imol <br /> Yes No If Yes, Refer to Site Mitigation�.for Evaluation <br /> 2. Recom mand Site Ctcl <br /> i V11. REVIEW EVALUATION - TO aE COMPLETED 3Y A SUPERVISOR/SENIOR <br /> C^NCS:R �+ITM STAFF RECClWENDATION FOR CLOSURE YES NO REFERRED TO SITE itTIGAT,ION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF r <br /> EVALUATCR <br /> fE <br /> ! EH 23 80 (UGn XSHT)\5/90 i <br />