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SAN JOAQUIN PUBLIC 14EALTH SER ICES/ENVIRUN NTAL HEALa 1V1 SI0N <br /> 11 UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE � <br /> AE Of FACILS' Y CPS COCE <br /> DDRESS ARK IC # :r <br /> ` ANK SIE , TYPE <br /> i . 4ENERAL SITE NIST iY <br /> aci t i tV Status Cts oc Soi i/ Cant e 99g= <br /> f'jTanks(if r� <br /> availabte5 of Tank test brgt + iaa i <br /> 3%P m TANK HISTORY <br /> Tam tend es ai press test if yes, give datetk <br /> as a repair de to tank sVst Tie es, rht gas repaired? <br /> ns re+air `a inspedti ere scan les gnat ed s !0 TXE PN-Ct PH-0 /ECS <br /> � a aituraA`dastrge aastr S t -te lakaa ,a�:rfitt n thr» <br /> ]V1 RE AL HISTORY ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oft S' Les Ra ei es e t t See Tatar e fYear -3 uerage;A at Precipitation x 4 0 <br /> -Site wetl S> es ca r Tye irr utr <br /> cora S care S sore <br /> istance to tttsl fr Tach f ; f ; ft C it PIS C pts C pts' <br /> C 0 if C f <br /> R -ondition A onditionR std <br /> Site Feature - Loathing Potential Analysis E is met E is t E s t <br /> inimum Depth to groundwater from the Soft Sampte'(feet) >100 <br /> ratures in subsurface (applies to foothilts or mountain areas) N tlnkn reSnt <br /> veragd Annual Precipitation (inches) xxxxx <10 9 10-25 KXXXXXX 26-40\2 <br /> on-Made conduits which increase vertical migration <br /> i leachate (i.e., septic systems, water welts, 3 None Unknown resent <br /> Inique site features: Recharge area, coarse soft, nearby wetts. At least ore than <br /> AS <br /> None one one <br /> COLTO ALSA>>TOTA POINTS + + <br /> onpte ResultstS T R OR EI RANGE OF TOTAL POINTS 9 pts or more t - 48 pts 40 cats or loss <br /> , ' �" ' LEVELSE T X E S X; <br /> MAXIMUM ALL IASLE tI-T-X-E LEVEL s tP eta 1 50 50 50 1 I. NA\S <br /> apple Resutt: A OLTNE 1000 104 10 <br /> 2700 TP 5SIMJM ALLOWABLE TAP LEVELS Paia Ip�q 0y � <br /> EL 10,000 Wq 43 1hR <br /> OOTNCT'ES: ***If documitnted snitand/or ground water contamination Is present, tics not coaptete the teashing potential <br /> 2 analysis. (ie., site is currentty on UCT Comtamination List-for Peat or groLind water.) <br /> t1 if depth' is 5 ft. and < 25 ft., sere gpoints'. if depth'x 5 ft., do not use table <br /> \2 If precipitation Is C inches, sears C points. <br /> t Levels fcr S X are t ap t eabtat a Tis concentration' f 10 pies (ga ine)-or 100 tdieseia. <br /> Vt. STAFF REC N ATION/CONCLUSION <br /> ii W <br /> E <br /> Are ST E or TQM Concentrations llwabl LeretA Yes sa' <br /> Rocs rd Site Closure es If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION TO BE COMPLETEO BY A SUPERVI ORFS NtOR <br /> .0NCu9 WITH STAFF RECOMMENOATION FOR CLOSURE ES' U EFERREC TO SITE MITIGATION FOR EVALUATION ES G <br /> ATE REFERREC ATC CLOSURE LETTER NAILED f 1 <br /> ANE OF <br /> .VALUATOR <br /> EN 23 SC (UGTWKSNT)S / C <br /> : H 29 80 <br />