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LTH <br /> RONMENTAL <br /> COUGST WORKSHEETAFOR SITE CLOSURE EVALUATIONHEALTkdIV[SIGN DATE <br /> INgE;MN <br /> —"' 1 SWEEPS CCmE 3y VTANKvv11 IO # - SSii <br /> Tj7/y/l� oKP' / <br /> S F' <br /> 11. GENERAL SITE HISTORY <br /> ility Status Code V A�Doc.Sai L/Gw Cant Yes No <br /> Is permit current? Yes No Permit # - fac <br /> Number of Tanks at facility <br /> Age of Tanks(if available) I 1 Type of Tank Steel Fbrgl Sngl Oual <br /> III. TANK HISTORY <br /> Was Tank ? Yes No Failed precision test 7 Yes No If yes, give date(s) <br /> t <br /> Was a repairestedmade to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPX-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic Long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water D Ref/Year <br /> Average AnnuaL Precipitation A= 14 10-25 <br /> On-Site Wells) Yes No Number & Type Irr Dam Pub <br /> S Score s Score 5 Score <br /> Distance to WeLL(S) from Tank ft; ft; ft C 10 pts C 0 if 0 i pts OC if f <br /> R condition R condition R condition <br /> IV. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) <br /> E0 >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> None Unknown Present <br /> Average Annual Precipitation (inches) <br /> xxxxxx <10 9 10-25 xxxxxXx 26-40\2 <br /> Man-Made conduits which increase vertical migration Nam Unknown Present <br /> of leachate (i.e., septic systems, water wells, ponds) <br /> At Least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx Nang one one <br /> y <br /> COLUMN TOTALS>»TOTAL POINTS <br /> Sample Result: (B T XI�OR EE) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts pts o <br /> SP µ A -e8– / V B T X E e T % <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1- NA\3 <br /> GASOLINE 1000 100 10 <br /> Sample Result' _O�1� o M IMUM ALLOWABLE TPN LEVELS (PPM) <br /> s P; A iJ ' TPN DIESEL 10,000 7000 100 <br /> ..If documented soil and/or ground water contamination is present, do not ccoplete <br /> FOOTNOTES: the leechi <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 <br /> o 'YesNo of 10 ppm (gasoline) or 10,0,pgpm (7�diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION �Q�� b69A Ate)L/ p <br /> 1. Are BTX & E or TPH Concentrations > ALLowable Levels A,& ,Zx. s <br /> 2. Recommend Site Closure Yes Na if Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / <br /> / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />