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COY 11\dI\IIIY Tv v,n� In uC,\fY CGC\/I nGC /GYVl�nuuCYf �� uC nlutntnu <br />11. GENERAL SITE HISTORY <br />Is permit current? <br />YesNo <br />INC REFERRED TO SITE MITIGATION FOR EVALUATION <br />No <br />Permit # <br />- <br />Facility Status Cade <br />0oc.Soit/GW <br />Cont <br />Yes <br />10-25 <br />No <br />Yes <br />Number of Tanks at facility <br />No <br />Age of Tanks(if available) <br />�V <br />Type of Tank <br />Steel <br />Fbrgl <br />Dam <br />Sngl <br />Dual <br />III. TANK HISTORY <br />Was Tank tested?Yes <br />Yes <br />INC REFERRED TO SITE MITIGATION FOR EVALUATION <br />No <br />Failed precision test ? <br />Yes <br />g�j <br />No <br />If <br />yes, give date(s) <br />10-25 <br />Was a repair made to The tank system? <br />Yes <br />No <br />No <br />If yes, what was repaired? <br />�V <br />Was repair done under inspection? Yes <br />Irr <br />No <br />Dam <br />Were soil samples analyzed? <br />Yes <br />NoTPH-G <br />BTXE <br />TPH-D <br />Pb/EDB <br />Type of failure/discharge <br />catastrophic <br />long-term Leakage <br />overfill <br />unknown <br />S <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received <br />Yes <br />INC REFERRED TO SITE MITIGATION FOR EVALUATION <br />No <br />Depth to Ground Water <br />O Ref/Year <br />g�j <br />Average Annual Precipitation <br />A= <br />14 <br />10-25 <br />On -Site Well(s) <br />Yes <br />No <br />I I <br />Number & Type <br />Irr <br />Dam <br />Pub <br />S <br />Score <br />S <br />Score <br />S <br />Score <br />Distance to Well(s) from Tank <br />ft; ft; ft <br />C <br />10 pts <br />C <br />9 pts <br />C <br />5 pis <br />0 <br />if <br />0 <br />if <br />0 <br />if <br />R <br />condition <br />R <br />condition <br />R <br />condition <br />V. Site Feature - Leaching Potential Analysis <br />E <br />is met <br />E <br />is met <br />E <br />is met <br />Minimum Depth to groundwater from the Soil Sample (feet) '%,,^,—/3z7 <br />>100 <br />51-100 <br />I <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />I O <br />None <br />Unkrrown <br />Present <br />Average Annual Precipitation (inches) <br />xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknwwn <br />Present <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />At least <br />More than <br />x//x��xx/�xx <br />None <br />one <br />once <br />COLUMN TOTALS>>>TGTAL POINTS <br />( O <br />- <br />Q� <br />I O <br />* <br />@ <br />i=3 <br />Sample Result: T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />41 4a pts <br />40 t ass <br />,(B <br />�/ <br />l / IV D <br />BT <br />X E <br />9 <br />T <br />X <br />E <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />1 <br />50 <br />50 50 <br />.3 <br />.3 <br />1. <br />1. <br />NA\3 <br />Sample Result: <br />GASOLINE <br />1000 <br />1D0 <br />10 <br />A J I <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />IVY <br />TPH <br />D[ESEL <br />10,1100 <br />1000 <br />100 <br />FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the Le= potential <br />analysis. (i.e., site is currently on UGT 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 />\2 If precipitation is > 40 inches, score 0 points. <br />\3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX & E or TPN Concentrations > Allowable Levels I*YesI INo <br />2. Recommend Site Closure Yes Na If Yes, Refer to Site 1Mitigation for <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />� V o M i(3 J: o r <br />_.l oXverrateS. <br />K Aa s A_&wd) C67_' <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE <br />YES <br />INC REFERRED TO SITE MITIGATION FOR EVALUATION <br />YES <br />DATE REFERRED <br />/ / <br />DATE CLOSURE LETTER MAILED <br />/ / <br />NAME OF <br />EVALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />