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11. GENERAL SITE HISTORY <br />Is permit current? <br />es <br />ES <br />o <br />LIO <br />ermit # <br />- <br />acility Status Code <br />o <br />cc.Soil/GW Cont <br />as <br />/ <br />o <br />n -Site WeLL(s) <br />umber of Tanks at facility <br />ere soil samples analyzed? <br />ge of Tank(if available) <br />PH-G <br />o TXE I IT <br />ype of Tart( <br />heel. <br />I b/EDB <br />brgl <br />am <br />ngl <br />I Dual <br />I <br />III. TANK HISTORY <br />as Tank tested? <br />as <br />ES <br />o <br />LIO <br />ailed precision test 7 <br />es <br />of/Year <br />o <br />If <br />yes, give date(s) <br />/ <br />as a repair made to the tank system? Yes No 1 11f yes, what was repaired? <br />n -Site WeLL(s) <br />as repair done under inspection? es a <br />ere soil samples analyzed? <br />es <br />PH-G <br />o TXE I IT <br />unber 8 Type <br />PH -D <br />I b/EDB <br />Type of failure/discharge <br />am <br />atastrophic <br />long-term leakage <br />I <br />iDverfilt <br />known <br />1 <br />10ther: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received es <br />RECOMMENDATION FOR CLOSURE <br />ES <br />o <br />LIO <br />epth to Ground Water <br />20 <br />of/Year <br />4^ •/ ;,,7, <br />verage Annual Precipitation <br />= <br />4 <br />0-25 <br />n -Site WeLL(s) <br />es I <br />AME OF <br />o <br />I <br />unber 8 Type <br />Irr <br />I <br />am <br />I <br />ub <br />S <br />core S <br />0 pts C <br />core S <br />pts C <br />core <br />pts <br />i stance to We L(a) from Tank <br />ft; ft; ft C <br />0 <br />if 0 <br />ondition R <br />is met E <br />if 0 <br />ondition R <br />is met E <br />f <br />ondition <br />s met <br />R <br />Site Feature - Leaching Potential Analysis E <br />inimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />1-100 <br />25 -SOLI <br />ractures in subsurface (applies to foothills or mountain areas) <br />None q <br />Unknown <br />Present <br />verage Annual Precipitation (inches) XXxx <br /><10 9 <br />10-25 KXXxxxx <br />26-4012 <br />an -Made conduits which increase vertical migration <br />f Leachate (i.e., septic systems, water weLLs, ponds) <br />None 9 <br />Unknown <br />Present <br />pique site features: Recharge area, coarse soil, or wells. <br />At leastore <br />than <br />LMuncipal=>2000 ft; domestic=>500 ft; irr/agricultural=present] xxxx <br />None <br />one <br />one <br />COLUMN TOTALS>>>TOTAL POINTS <br />' <br />�mpLeoRVesul (B T X OR E) <br />PP"PPN4 <br />RANGE OF TOTAL POINTS 9 pts <br />or more 41 - <br />48 pis 40 pts or less <br />BT <br />X <br />E B <br />T <br />X <br />E <br />Fg' p` <br />Ty .A syn <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 <br />50 <br />50 <br />50 .3 <br />.3 <br />1. <br />1. NAj3 <br />ample Result: <br />ASOLINE 1000 100 10 <br />1G1 <br />ALLOWABLE TPH LEVELS (PPM) <br />100 <br />JTAXIMUM <br />May TPH4 <br />IESEL 10,000 1000 <br />OOTNOTES: ='•If documented soil and/or ground water contamination is present, do not complete the leaching potential <br />analysis. (i.e., site is currently on UST 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 />12 If precipitation is > 40 inches, score 0 points. <br />for BTXBE applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />\3 Levels are not <br />VT. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes N o <br />2. Recommend Site Closure es o N�, If Yes, Refer to Site Mitigation for Evaluation <br />VII REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br />DNCUR WITH STAFF <br />RECOMMENDATION FOR CLOSURE <br />ES <br />LIO <br />EFERRED TO SITE MITIGATION FOR EVALUATION ES <br />O <br />ATE REFERRED <br />/ f 6:;i-/ <br />ATE CLOSURE LETTER MAILED <br />AME OF <br />bc <br />VALUATOR <br />EH 23 80 (UGTWKSHT)\5/94 <br />