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IIAR "QUIN C PUBLIC HEALTW SERVICES/ERVIRONMENTALNeAL1,'.01v1SIoH <br /> 3. UOST WORKS14CET FOR SITE CLOSURE EVALUATION ATE <br /> AME Of FACILI Y EPS cooe <br /> DORES AN 10 # <br /> ANK SIZE <br /> 11. GENERAL SITE <br /> 111� TANK HISTORY <br /> Is Tank test a sited presisa test T f yes, give date(s) <br /> as a repair sr syst N lids, theti ired? <br /> a repair d r iirSp to T es sail les sra lyzed? as 10 <br /> lva REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SItE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> it samptos R i verge Aryvat Precipitation 4 0-25 <br /> - its Wait($ <br /> S core S core s core <br /> Istante to we C 0 Pts C ots C PIS <br /> 0 f 0 if 0 <br /> Site Feature - Leaching Potential Anala is <br /> tis R ondition A ondition A <br /> met E is met E <br /> Jnii4A 0eeth to Sr water from the Sail to (feet) >100 <br /> ractures In subsurface (applies to foothills or mountain areas) 16 None <br /> varage Annuat Precipitation (inches) xxxx <10 9 10-25 KXXXXXX 26.40\2 <br /> ,jn-Made conduits which increase vertical, migration <br /> f leachate (1.*., septic system, water wells, ponds) It unknow" resent <br /> Inique site features: Recharge area, coarse soft, nearby wells. At (east ore than <br /> xxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS # ?3 <br /> ample Result: IS T A OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> 8 1 X E 8 T X E <br /> MAXIMUM ALLOWABLE 8-T-X-E LEVELS (PPM) 1 50 50 50 .3 ,3 1. to (HA\3 <br /> 0"Pte Result: ASOLtNE 1000 100 10' <br /> 13ro AXINJM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTES: ***If doctrented soil /or ground water contamination is present, do not complete the teaching potentiat <br /> analysis. (i.e., site Is currentLy on LOT Contamination List for soil or ground water,) <br /> \1 If depth is > 5 ft. and < 25 ft., scope 0 pointe. If depth -5 ft., do not us* table, <br /> e#1 30 \2 If precipitation is ), 40 inches, score 0 points. <br /> \5 Levels far STx E re t a lies to at a TPH concentration of 10 ppm (gasoti7e) or 100 ppm (dieset). <br /> V). STAFF RECOWEROATION/CONCLUSION <br /> [1EAr*W11MTX & E or TAN Concentrat I ons > At towable Levels s ii <br /> 2 2. <br /> . RecomPandSate Cttstrre es If Yes, Refer to Site Mitigation for Evatuation <br /> Vtl. REVIEW EVALUATION TO Of COMPLETED BY A SUPERVISOR/SENIOR <br /> EfERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> LETTER ILEO <br /> 2=7= /7777 <br /> EN 23 80 (UGTWKSHT)\S/90 <br /> EH 29 80 <br />