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SRN lCACUIN COUNTY P 4EALTH SEERVICSS/E4VIRCNME4TAL 4EALTH DIV& OATE <br /> UGST '.l.n. HEET FOR SITE CLOSURE clALUATICH <br /> / SVEEPS CCOEI �/ / Z— <br /> Ud �c <br /> Cf FACILITY r,J�'(, C`l�� TANK to <br /> 3K SICEIl�(f FUEL TYPE US <br /> [N e•• <br /> 'c4ERAL SITE HISTCRY N Da:.Soil/Gw CantlYes No <br /> emit a Facility Status Code <br /> xrmi: currant? Yes No Sngl Oual <br /> Age of Tanks(if aveil <br /> rcer of Tanks at facilityahle)I Type of Tank Steel Fhrll <br /> TARK 4ISTORY <br /> date(S) <br /> Tank :esteYesl NOI - Failed Precision test T Yesl INo If yes, live <br /> dTl / <br /> s a e tank syscm7 Yes No If yes, what was repaired? <br /> repair made to thetank <br /> .as repair done order ti on7 Yea INoI were soil samples analyzed? Yesl Nol BTXEI TPH-G ITPN-)I 9b/EDB <br /> !pe of failure/discharge I IcatastrophM Ilong•tera Leakage )overfill unknown other: <br /> R£ACVAL 4(STORY (ATTACH INSPECTION REPORT FOR SITE DETAIIS/CILECT DATA FOR LEAC41MG POTENTIAL AANALSISAverage ACICUAL pi utlon Ae 14 10-25Sall;oil Sall Received Yes No Depth to Groud water V,I Ref/Year <br /> Number S Type trr Doo IPS S Scare S Score S Score <br /> ]n•Site wells) Yes No C 9 pts <br /> if C 5 pts <br /> ft; ft; ft C pts O if 0 if <br /> oistarce to Well(s) from Tank 0 it cotdition R condition <br /> R condition R t E is met <br /> L Site Feature - Leaching Potential Arelc is met E is me <br /> Ysis 51-100 �' 125•SO\1 <br /> I >100 <br /> Minimum Depth to 9roudwater from the Soil Sample (feet) 5-0' lN�norn presmc <br /> None 9 <br /> ' thills;Fractures in subsurface (applies co fooor mou Iain areas) 110_u aax 26-40\2 <br /> xxxxxx <10 I 9 Xxxx <br /> Average Annual Pree ipitation (inches) <br /> q <br /> Man-Node conduits which increase vert ieal migrationU�pwn Present <br /> / <br /> of leachate (i.e., septic systems, water wlls, Ponds) Nor* At least More than <br /> `I <br /> Unique site features: Recharge area, coarse soil, nearby Wel s. xxx= None am ane <br /> COLUMN TOTALSoWOTAL POINTS 40 is or less <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more <br /> - 48 Pts P <br /> B T XE B T E NAV <br /> MAXIKAI ALLOWABLE B-T•X-E LEVELS (PPM) 1 50 50I X 50 .3 .3 1. 1' 10 <br /> GASOLINE 1000 100 <br /> Sample Results IMAXIMl ALLOWABLE TPN LEVELS (PPM)N1000 100 y <br /> PR DIESEL 10,000 <br /> l the leeching Potential <br /> FOOTNOTES: •'•if documented soft ardor ground water contamination is present do ro oep water.) <br /> analysis. (i.e., site is currently an UGT Contamination S it <br /> dornotn usmrtabl ground <br /> \1 if depth is > 5 ft. end s 25 ft., score 0 PaIf (diesel). <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 levels for aTXSE are not applicable at a TPN concentration of 10 ppm <br /> V1. STAFF RECOMMENDATION/CONCLUSION Dy YG4eS-,L-v, (e--) <br /> No <br /> 1. Are BT)I i E or TPM Concentrations > Allowable Levels •Tea 072 I = Ok- <br /> 2. Recameetd StU Closure Yea No elf Ycs, Refer to Site Mitigation tar Evalua ion <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERI SCR/ ENICR <br /> CCNC'R WITH STAFF RECCwMEAOATICN FOR CLOSURE YES NO IAEFERAED TO SITE MITIGATION FCR EVALUATION YES NO V <br /> DATE REFERRED DATE CLOSURE LETTER NAILED <br /> NAME OF <br /> EVALUATCR1 �j. _. <br /> G•r <br /> EH 23 30 (UGTVKSHT)\5/90 <br />