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It. GENERAL SITE HISTORY <br />is permit current7 as o it IFacitity StaCus Code oe.Soil/Gu Cont es <br />'Wdxr of Tanks at facility I np of TAnknrif avaitahtel I ITvne of Tank 6teeL I lFbrqt, I krnt <br />Dual <br />tit. TANK HISTORY <br />ms Tank tested? es o ailed precisi test ? as I o If yes, give dates) / <br />as a repair made to the tank system? esNo f yes, what was repaired?' 3j. <br />as repair done under inspection? as go ere soil samples analyzed? as a T PH -G PH -O b/EDB <br />ype of failure/discharge atastrophic long-term leakage verfIIE known 1 10cher: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />oil Samples Received <br />as <br />o <br />/ / <br />epth to Ground Water <br />¢ % <br />of/Year <br />verage Annual Precipitation <br />= <br />4 <br />0-25 <br />-Site Wells) <br />es <br />I <br />iio <br />umber & Type <br />Irr <br />cm <br />ub <br />S <br />Score S <br />10 pts C <br />Score S <br />9 pts C <br />core <br />pts <br />istance to Wells) from Tank <br />ft; ft; ft C <br />0 <br />'f 0 <br />onditi m R <br />is met E <br />if 0 <br />condition R <br />is met E <br />f <br />ordition <br />s met <br />R <br />i. Site Feature - Leaching Potential Analysis E <br />inimLm Depth to groundwater from the Soil Saaple (feet) <br />>100 <br />1-100 <br />25-50\1 <br />ractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />resent <br />Average Amual Precipitation (inches) KXXXXX <br /><10 9 <br />10-25 xxxxxxx <br />26-40\2 <br />an -Made conduits which increase vertical migration <br />at 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 />are than <br />xxxx <br />None <br />one <br />one <br />COLUMN TOTALS—TOTAL POINTS <br />+ <br />+ <br />ample Result: (B T X OR E) <br />RANGE OF TOTAL POI NTS9 pts or more 41 - 48 pts 40 pts or less <br />B <br />T <br />X E 8 <br />T <br />X <br />E <br />MAXI" ALLOWABLE B -T -X -E LEVELS (PPM) 1 <br />50 <br />50 50 .3 <br />.3 <br />1. <br />1. NA\3 <br />ample Result: <br />ASOLIHE <br />1000 100 10 <br />AXIMUM ALLOWABLE TPH LEVELS (PPM) <br />10,000 1000 100 <br />TPH)DIESEL <br />FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the teaching 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 ppm (diesel). <br />Vt. STAFF RECCMMENOATION/CONCLUSION <br />1. Are BTX &.E or TPH Concentrations > Allowable Levels Yes o <br />2. Recommend Site Closure as o If Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO BE CCMPLETED BY A SUPERVISOR/SENIOR <br />CONCUR WITH STAFF RECCMMENDATION FOR CLOSURE <br />ESI0 EFERRED TO SITE HITICATICN FOR EVALUATION ES 0 <br />ATE REFERRED <br />/ / <br />ATE CLOSURE LETTER MAILED <br />¢ % <br />DAME OF <br />:VALUATOR <br />EH 23 80 (UGTt.XSHT)\5/90 <br />r <br />