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SAH 1O oU,m PUBLIC HEALTH SEZVTC=S/E4VIRCNMENTAL HEAVIS[CN <br /> j T wORKSHEE FOR SI-12- CLOSURE EVALUATION 0 DATE <br /> SWEEPS CCOE <br /> NAME OF FACILIT' <br /> Ia 1 A 1--Zl � (TANK [D <br /> AQOAESSI <br /> (TANK 5[LI � (FUEL 77PS1, <br /> II. GcVERAI SITE HISTCRY <br /> Iis permit current?IYesl IHoI Permit *I - Facility Status C;del IDpc.SoillGi CantIYesi(Nal <br /> Hamper of hanks at facility+ `Age of ranks<if avaiLadle)I IType of ianklSteell IFargLj ISngl) Dual <br /> :11. TANK 4ISTOR7 <br /> Vas tank Lested7iYes <br /> No <br /> (Failed precision test ?`Yes` INo( If yes, give date(s) <br /> `':as a repair made to the tank system? Yes NDI IIf yes, weat was repaired?( <br /> 04as repair done underinspectionllYesl (NCI luere soil samples anaLYZea?IYes l INo{ BTX- <br /> I PH-al iTPH-OI IPtr/EDeI <br /> "ype of failure/discharge) Icatastrcphicl (long-term leakage) )overfill) (unknown) Iattter: <br /> [V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/CCLL+T DATA FOR 1aCHING POTEINTIAL ANALYSIS) <br /> ;Soil Samples ReceivediYes l No (Depth to Grnuna Water) (Ref/Year )Average Annual Precipit3tionlA=It4 I10-S <br /> ICn-Site WelL(s)IYes I iNoI (Number b Typel Iirrl iDaml IPual I <br /> S Scare S Sczre S Scare <br /> Distance to We(L(s) from Tankl ft; ft; C 10 pts C 4 pts C 5 pts <br /> a if a it a if <br /> R condi t i on R condition t candi t i on <br /> V. Site Feature - Leaching Potential Analysis E is met I E is .met I = is met <br /> (Minimum Depth .o groundwater from !te SoiL Sample (feet) l >10Q I ISi-100 l Zs-d0\1 <br /> 1"11ctures in subsurace <acplies .e footiti[ls or mountain areas) ( f Hcre I Unknown I )Present <br /> I_ <br /> lAverage annual Precipitation (inches) lx=xxxl <10 I 9 I la-L- Ix l 25-40\Z <br /> Man-!lade conduits which incresse vertical migration <br /> j <br /> :af leachate (i.e., septic systema, water wells, ands) I gone i Unknown I Presmt <br /> Unique site features: Recharge area, coarse soil, nearby wells. I At leastMore than <br /> ! <br /> i �xxxxxx� None ( one one <br /> * ) �_ <br /> �� CJLUMN TOTALS»>iOTAL POINTS <br /> SaincLe Result- (8 i X OR E) RANGE OF TOTAL POINTS 49 pts or more I Gi - 4.3 pts l =0 pts or less <br /> Is <br /> PC x = Jab * 1 31E E <br /> �S�C 1►tfa = . 3 C��y K9 MAXIMUM ALLCWABLE 3-r-1-i- LESS CPPM) 1 o� 50I 50 .3 1 1. I HA\3 <br /> :Sample Result: GASQLINE 1000 I 10Q I 10 <br /> Sf� i PidG=,?•a AV MAXI" ALLOWABLE TPH LEVELS (PPM) <br /> TPH I DIES -'a'000coo I 1000 l 1� <br /> PcOTHOTES: '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 /> j \1 If depth is > 5 ft. and < S ft., score 0 points_ If despot =5 ft., do not use table- <br /> \2 If precipitation is > 44 inches, score 0 points_ <br /> \3 Levels for 3TXEE are not applicable at a TPH concentration of TO ppm Cgasalirse) or t0Q Fpm (diesel). <br /> i <br /> VI. STAFF RE=MMENOATIOH/=CLUSiCM <br /> 1. Ara RTX ° or TPH Corhtrations > Allowabie levels I-Yesl INo} <br /> 2. Recommend Site CLosurelYesl INo( ?If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATICN - TO 3E COMPLETED 3Y A SUPERVISCR/SENIOR <br /> CrNCJR WITH STAFF zEC:7MEVDATICN FOR C OSUREIYE51 IHOI iRE.=-ZRE7 TO SIE MITIGATION FCR cIALUATICN�YESi IHOI <br /> DATE REFERRED! / ! (DATE CLOSURE L_"TTc3 MAID( ! / <br /> NAME OF l <br /> EVALUATORI <br /> EH 23 30 (UGTUKSHT)\5/90 <br />