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.. r_CUCOAI ¢TTF HISTORY <br />s permit current? Yes No Permit # - Facility Status Code Doc.SOil/GW Cont Yes No <br />lumber of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br />III. TANK HISTORY <br />Was Tank tested? <br />Yes <br />No <br />Failed precision test ? <br />Yes <br />Ref/Year <br />No <br />If <br />yes, give date(s) <br />14 <br />Was a repair made to the tank system? <br />Yes No <br />If yes, what was repaired? <br />Was repair done under inspection? Yes <br />No Were soil samples analyzed? <br />Yes <br />No <br />BTXE <br />TPH-G <br />TPH-0 <br />Pb/EDB <br />Type of failure/discharge <br />catastrophic long-term leakage <br />overfill <br />unknown <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALTbib) <br />Soil Samples Received <br />Yes <br />No <br />Depth to Ground Water <br />Ref/Year <br />0,/, ; <br />Average Annual Precipitation <br />A= <br />14 <br />10-25 <br />On -Site Wells) <br />Yes <br />No <br />Number & Type <br />Irr <br />Dan <br />Pub <br />S <br />Score <br />10 pts <br />S <br />C <br />Score <br />9 pts <br />S <br />C <br />Score <br />5 pts <br />Distance to Wells) from Tank <br />ft; ft; ft C <br />0 <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />R <br />V. Site Feature - Leaching Potential Analysis E <br />Minimum Depth to groundwater from the Soil Sade (feet) yN <br />>100 <br />51-100 <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />Present <br />Average Annual Precipitation (inches) 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 />Unknown <br />Present <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />At least <br />More than <br />xxxxxx <br />None <br />one <br />one <br />+ <br />+ <br />= LIQ <br />COLUMN TOTALS>>>TOTAL POINTS <br />Sam4a Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more <br />- 48 pts <br />40 pts or less <br />g c f4a; , 09:4* 'C= d. A . coJsPi <br />d.13;. P.M. B T X E <br />B T X E <br />� = A- 6) - - W,4 MAXIMUM ALLOWABLE B -T -X -E LEVELS (RPM) 1 50 50 50 <br />.3 .3 1. 1. <br />NA\3 <br />S le Result: <br />GASOLINE 1000 <br />100 <br />10 <br />Ai 5'-0tV ^ -nAd--4 <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />ALID-, /.op/J�_TPH—C <br />DIESEL 10,000��L <br />1000 <br />100 <br />L I I'll <br />FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching 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 el). <br />VI. STAFF RECOMMENDATION/CONCLUSION %v Uh(� Tt I' Z <br />1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br />2. Recommend Site Closure Yes No*If Yes, Refer to Site Mitigation for EvaluatiQ ^j•4 <br />VII. REVIEW EVALUATION - TO BE COMPLETED dY A SUPERVISOR/SENIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YE5NO REFERRED TO SITE MITIGATION FOR EVALUATION YESI NO <br />DATE REFERRED / I DATE CLOVRE LETTER MAILED I / <br />NAME OF <br />EVALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />