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It. GENERAL SI <br />III. TANK HISTORY <br />as Tank tested? <br />es <br />V <br />a <br />EFERRED TO SITE MITIGATION FOR EVALUATION <br />ailed precision test ? <br />es <br />IV <br />o <br />I If <br />yes, give date(s) <br />K61,1, / <br />as a repair made to the tank system? Yes No f yes, what was repaired? <br />-Site Well(S) <br />Jas repair done under inspection? <br />eso ere soil samples analyzed? <br />es <br />o <br />I <br />TXE <br />PH -G <br />PH -0 <br />b/ED8 <br />ype of failure/discharge <br />atastrophie long-term leakage <br />verfitl <br />known <br />cher: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received <br />eso <br />0 <br />EFERRED TO SITE MITIGATION FOR EVALUATION <br />epth to Ground Water <br />0 <br />of/Year <br />verage Annual Precipitation <br />= <br />4 <br />0-25 <br />-Site Well(S) <br />IYes <br />o <br />umber S Type <br />I <br />Irr <br />an <br />ub <br />S <br />score <br />10 pts <br />S <br />C <br />Score S <br />9 pts C <br />core <br />pts <br />)!stance to Wetl(s) from Tank <br />ft; ft; ft C <br />0 <br />'f <br />onditfon <br />is met <br />0 <br />R <br />E <br />if 0 <br />condition R <br />is met E <br />f <br />ondition <br />s met <br />R <br />Site Feature - Leaching Potential Analysis E <br />inimum Depth to groundwater from the Soil Sample <feet) <br />>100 <br />1-100 <br />25-50\1 <br />ractures in subsurface (applies to foothills or mountain areas) <br />Nage <br />Unknown <br />resent <br />verage Annual Precipitation (inches) KXXXXX <br /><10 <br />9 <br />10-25 xxxxxxx <br />26-40\2 <br />an -Made conduits which increase vertical migration <br />f leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />resent <br />pique site features: Recharge area, coarse soil, nearby wells. <br />At least <br />4ore than <br />xxxx <br />Nate <br />one <br />one <br />COLUMN TOTALS»>TOTAL POINTS <br />* <br />+ <br />ample Result: (B T X OR E) <br />RANGE OF TOTAL POINTST9 pts or more <br />41 - 48 pts 40 pts or less <br />B <br />T <br />X <br />E <br />B T <br />X <br />E <br />MAXIMLM ALLOWABLE B -T -X -E LEVELS (PPM) 1 <br />50 <br />1 <br />50 <br />50 <br />.3 .3 <br />1. <br />1. HA\3 <br />ample Result:ASOLINE <br />1000 <br />100 10 <br />AXIMUN ALLOWABLE TPH LEVELS (PPM) <br />10,000 <br />1 1000 100 <br />TPN <br />IESEL <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 BTXBE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECCMMENDATION/CONCLUSION <br />1. Are BTX E or TPH Concentrations > Allowable Levels Yes o <br />2. Recommend Site Closure es I No I If Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE <br />rESI <br />0 <br />EFERRED TO SITE MITIGATION FOR EVALUATION <br />ES <br />0 <br />ATE REFERRED <br />ATE CLOSURE LETTER MAILED <br />SAME OF <br />:VALUATOR <br />EH 23 80 (UGTWKSHT)\5/900 40 <br />If <br />