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�tTY .,p <br /> ...u9ESS D <br /> TANK SIZE FUEL TYPES i <br /> il. GENERAL SITE HISTORY nt <br /> Permit # - Facitity status Code ooC.solllor ca1w W <br /> Age of Tanks(if available) <br /> - pr <br /> FIs permit current? Yes NO Type of Tank steer Fbrgt sngt Dual <br /> Number of Tanks at facility <br /> — <br /> Ili. TANK H1570RY No Yes N° If yes, <br /> give dates) / <br /> t Failed precision test <br /> Iwas Tank tested? Yes x repaired? TQ/y <br /> I Nc If yes, what was rep Pb/1 <br /> Was a repair made to the tank system? Yes Were soil samples analyzed? Yes No <br /> BTXE` TP -G TPH-D <br /> done under inspection? Yes NO unknown other: <br /> was repairoverfill <br /> Type o{ failure/discharge <br /> catastrophic long-term leakage <br /> 11 L HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL <br /> 0 age A nuAalAPrecipitation�A= 14 <br /> IV. REMOV11 A . Ref/Year <br /> No Depth to Ground water <br /> Soil Samples Received Yes Dao Pub S Score <br /> Number & Type Irr S Score S. Score C 5 pts <br /> on-Site Well(s) Yes N0 10 pts C i pts <br /> ft C 0 i f 0 if <br /> !_ft; �__�—{t' 0 if Condit <br /> Distance to Wells) from rank R condition R condition E is met <br /> E is met E is met <br /> Potential Analysis �51-100 , ` 25-51 <br /> �V. Site Feature - Leaching >109 <br /> Sample (feet) rese <br /> Minimum Depth to groundwater from the Sail —3%3 �PSame l None Unknown <br /> (applies to foothills or mountain areas) lJ 9 10-25 �xx�, 26-4 <br /> ,Fractures in subsurface (apP xxxxxx <10 <br /> Average Annual Precipitation (inches) Unknown Presc <br /> None i <br /> Man-Made conduits which increase vertical migration <br /> ponds) At least More <br /> iof leachate (i.e., septic systems, one <br /> wells. <br /> j None <br /> Recharge area, coarse soil, nearby <br /> unique site features: <br /> COLUMN TOTALS >>TOTAL POINTS 41 - 48 pts 40 pts c <br /> +y RANGE OF TOTAL POINTS 49 pts or more <br /> Sample Result, (B 7 X OR E) B T X E T X E. NA\3 <br /> 1. <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 3 .3 1 <br /> 100 10 <br /> j GASOLINE 1090 <br /> Sample Result: MAX1Ml1M ALLOWABLE TPH LEVELS (PPM) 10 900 <br /> 1,000 100 <br /> DIESEL <br /> TPH do not complete the leaching pot <br /> ***If documented soil and/or groom water contamination is present, <br /> FOOTNOTES: rots. if depth <=5 ft., do not use table. <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground grater. <br /> \1 if depth is > 5 ft. and < 25 ft., score 0 pints. (gasoline) or 100 ppm (dies- <br /> \2 If precipitation is > 40 inches, score 0 P° <br /> \3 Levels for ST)(&E are not applicable at a TPH concentration of t0 ppm <br /> VI. STAFF RECOMMENDATION/CONCLUSION �/ ` <br /> 1, Are gTX & E or TPH Concentrations > Allowable Levels *Y�I /\ANO for Evaluation <br /> �2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation <br /> 3 �NO <br /> I <br /> VII. REVIEW EVALUATION TO BE COMPLETED BY A E ERVISO�NONIOIREFERRED TO SITE MITIGATION FOR EVALUATION YES <br /> i CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE�YES <br /> / DATE CLOSURE LETTER MAILED <br /> DATE REFERRED / <br /> NAME OF <br /> EVALUATOR; <br /> w EH 23 80 (UGTWKSHT)\5/90 <br />