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�j ATE �r� r <br /> ,A SAH ;JOA u%A CL pLJBLIC HEALTH SERV ICESlEHYIRON'LUAT1 <br /> UGST WORYSHEET FOR SITE CLOSURE EVALUATI� EEPS CGDE CS (} <br /> IF <br /> c 7`' GLr6p� <br /> ATE OF FACILITY �j �{ CC�/l� ANK 10 3 - 0 U <br /> CORESS � <br /> k I rs } UEL ;TYPE r <br /> LANK St [! V V v +r <br /> it. GENERAL SITE HISTORY11 oc.Soil/GW Cont es o <br /> Facility Status Code 'J <br /> o ermit p - <br /> is permit current7 es of Tarek feel Fbrgl ng! Dual <br /> umber of"Tanks at facility <br /> ge of Tanks(if available) L ype <br /> i <br /> TANK HISTORY <br /> If yes <br /> ns Tank tested7 es o ailed precision test ? as o g <br /> as a repair made to the Lank; system? es No f yes, what was repaired? <br /> es o ere soil samples analyzed? as o T PH-G <br /> PH-0 b/E08 <br /> 'as repair done under inspection? samples <br /> ype of failure/discharge I patastrophic I Ilong-term Leakage verfil! nknown Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSP CT ON REPORT FOR SITE .DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received Ke goepth to Ground Water eF/Year verage Annual PrecipitationSite Wells) es Type Irr om ub <br /> S care S core S. core <br /> istance`to WeIL(s) from Tank #t; ft; ft C 0 pts_ C pts C pts <br /> 0 if 0 if 0 f <br /> R =ondition R condition R ordition <br /> 1. Site`IFeature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater:from the Soil Sade tfeet)�-+ >100 1-100 25-50\1 <br /> Fractures in subsurface (apple es to foothills or mountain areas) O None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 25-40\2 <br /> an-Made conduits which increase vertical migration l <br /> Df leachate (i.e., septic systems, water wells, ponds) Ypu� J" Hone Unknown resent <br /> - 1 <br /> n;que site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxx Hone } �I one one <br /> COLUMN!TOTALS>>>TOTAL POINTS 1� + ! U a - U <br /> ample Result: (B T X OR E) '' RANGE OF TOTAL POINTSF9 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T JXE <br /> MAXIMLM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: ASOLINE 1000 100 10 <br /> GOOfr-• qAxiMUM ALLOWABLE TPH LEVELS (PPM) <br /> fPf{D 3150 TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is -present, do not complete the leaching potential <br /> arsalysis. (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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel), <br /> Vt. STAFF RECCMMENDATION/CONCLUSION he�u. yyl -I(-��y'Qi�y2(f�e .� -/'<�� •� C S-I r S�f <br /> 1. Are 13TX & E or TPH Concentrations > Allo able Levels Yes o (/Jy ��`i &vy � '�� -; <br /> 2. Recommend SiteClosure es o if Yes, Refer to Site Mitigation for Evaluation l� <br /> V[I. REVIEW EVALUATION - TO BEiCCHPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENOATION FOR CLOSURE ES 0 EFERREO TO SITE H[TIGATION FOR EVALUATION ES. 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILEDy % <br /> FAME Of <br /> G :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />