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MR JVAWuie uvu AILIV HEALTH SERVICES/ENVIRONMENTAL' HEALT `z',IStON <br /> I. U - ;RKSHEET FOR SITE CLOSURE EVALUATION <br /> A. N DATE / Z <br /> t <br /> NAME OF FACILITY r PS CODE z?pon <br /> i <br /> �h ADDRESS pld,2Athe TANK I0 9 <br /> 1 TANK SIZE FUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Yes NoPermit 0 - Af A- Facility Status Code Doe oitOW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) (vyt� ype of Tank Stee brgt Sngl oust <br /> I l l. TANK H I STORY <br /> Was Tank tested? Yes No Failed precision test Yes No if yes,' give dates}I Vi q <br /> :as a repair made to the tank system? Yes NoI 'w�'� <br /> repair done under inspection? Yes Were soil samples analyzed? Yes8TXE} TPH-G TPH-D Pb/EDB <br /> No ,F <br /> Type of failure/discharge cat strophic long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSP CTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Yater ZCf Ref/Year �e ; N Ave4rag* Annual Precipitation A= 14 10-25 <br /> On-site Wells) Yes NoHunber & Type 1, rr Dan Pub ;- <br /> S score s Score s Score <br /> Distance to Well(S) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is ;met E is met E is met <br /> Minimum Depth to groundwater frac the Sot[ Sample (feet) Zp-w�c10 >1`00 51-100 O 25-501,1 <br /> Fractures in subsurface (applies to foothills or mountain areas) �0 No Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx a10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration 1 <br /> of leachate (i.e., septic systems, water wells, ponds) None 1 Unknown Present <br /> Unique site features: Recharge area, coarse sail, nearby wells. .} At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS � <br /> Sample Result: (8 T X OR E) RANGE OF TOTAL POINTS 49 pts or,�more 41 - 48 pia 40 pts or Less <br /> B=N•D• X --4Z01?b <br /> ZZO b B T X E B T X E <br /> e a N.D. MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000; 100 10 <br /> MAXIMUM ALLOWABLE TPR LEVELS (PPM) <br /> 13M DIESEL 10 000 1000 100 <br /> 7PH 4 <br /> FOOTNOTES: ***If documented soil an:Vor ground water contamination is present, do not complete the teaching 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 465 ft.; do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. ii <br /> \3 Levels for STX&E are not applicable at a TPH concentration of 10 p;"I <br /> (gasoline} or 100 ppm (diesel). i <br /> VI. STAFF RECOMMENDATION/CONCLUSION 3POCI� t �40��� <br /> 1. Are BTX & E or TPN Concentrations > Al Yow able Levels *Yes rv► <br /> 2. Recommend Site Closure Yes Ho V *If Yes. Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> d 1 <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> 1 <br /> DATE REFERRED / (� /61 DATE CLOSURE LETTER MAILED <br /> NAME OF ' <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 f <br />