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SAH "m C Y PUBLIC HEALTH SERVICES/ENW RONMENFAL HEAL rV[SION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE s a <br /> AME OF FACILITY i' v /! -PEEPS COoe. <br /> nORESS <br /> 'ARK SIZE srzE ] POD UEL 'TYPE ¢ <br /> II. GENERAL SITE HISTORY <br /> Is permit current7 es o ermit 9 - aeiliiy Status Code oc.Soil/GW Cont es a <br /> umber of Tanks a[ facility ge of Tanks(if available) fig ype of Tank tee[ brgl ngl Dual <br /> III. TANK HISTORY <br /> a=Tank tested? es a 4,ited precision test 7 es o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> 'ns repair done under inspection? es a ere soil samples'analyzed7 es o TXE PN-G PH-0 b/ED6 <br /> ype of failure/discharge atastrophic long-term leakage verfill I known I lother- <br /> IV. REMOVAL HISTORY (ATTACH tNSPI TION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Vaterof/Year �'� ; verage Annual Precipitation = 4 0-25 <br /> l�v. <br /> -Site Ve[t(s) es a umber & Type I trr om <br /> S core S Score S core <br /> istance to Wells) from Tank ft• ft; ft C 0 pts C 9 pts C pts <br /> O f 0 if 0 f <br /> R ondition R rondition R ondition <br /> V. Site Feature - Leaching Potential Analysis E s met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample tfeet)/7l �s >100 1-t00 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) , None Unknown resent h` <br /> Average Annual Precipitation (inches) KXXXXX 410 9 10-25 KXXXXXX 26-40\2 <br /> .. 5 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systertns, water wells, pords) None unknown 5 resent <br /> ique site features: Recharge area, coarse soil, nearby welts. At least lore than <br /> xxxI <br /> xxx None one one <br /> COLUMN TOTALS—TOTAL POINTS + J + I D S <br /> r <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> ' B T X E B T X E <br /> MAXIMLH ALLOWABLE 8-T-X-E LEVELS (PPN) 1 50 SO 50 .3 .3 1. 1. NA\3 <br /> Sample Result: SOLINE 1000 100 10 <br /> pN– D D LAX1TRlM ALLOWABLE TAH LEVELS (PPM) <br /> TPH lESEL 10,000 1000 100 <br /> OOTHOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (f.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 ppm (diesel): <br /> V1. STAFF RECCMMEHOATION/CCNCLUSrON �' <br /> t. Are BTX $ E or TPN Concentrations > Allow b!e Levels Yese <br /> V_7;�k, G�EG1lUi <br /> 2. Recommend Site Closure es a If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE CCMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECCMMEM0ATI0N FOR CLOSURE YES O EFERREO TO SITE MITIdATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED '.y % <br /> TAME OF <br /> :VALUATOR <br /> CH 23 80 (UGTVKSHT)\5/90 <br /> } <br />