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SAN JOAQUIN C&WY PUBLIC HEALTH SER VICES/ERVIRONMENTAL SION <br /> 1. LI ST WORKSHEET FOR SITE CLOSURE EVALUATION ATE ZZ, <br /> AMS Of FACtLI fps CODE <br /> DRESS <br /> AND TO <br /> ANK SIZI! <br /> 11. GENERAL SITE HSRY <br /> Cont as 0 <br /> n9l, Dual <br /> 111. TANK HISTORY <br /> s Tank test sib prsLisi test If yes, give dateW I <br /> as a repair ds t the tar cyst T N yes, est r"!sed? <br /> no repair tyzed? ea 10 TXE PH_G PH-0 b/ED8 <br /> IV. AEMOVAL HISTORY (ATTACH INSPECTION REPORT FOR $ITE OCTAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oi I Sooptes, Ai verage Annuat Pretipitation 4 IC- <br /> -Si <br /> -Site Well(s <br /> S core S core S core <br /> Istance to Ve C 0 Pts C Pts C Pts <br /> 0 if It if 0 f <br /> R condition R ondition R <br /> Site Featuro - Leaching Potential Analysis E is met E is <br /> intioun Depth to groundwater from the Snit 5e (feet) a100 1-1 <br /> ractures in subsurface (applies to fooChi lts or mountain areas) <br /> varago A Precipitation (inches) Ass 410 9 10-25 Kxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> T teachat e (i.e., septic system, water wells, ponds) None Unkncnn resent <br /> Inique site features. Recharge area, coarse soil, nearby wells. At least or* then <br /> xxxxx None one one <br /> COLUMN T0TALS>>>TOTAL POINTS + 115, + 23 <br /> Ample Result: (3 T X OR 6) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pro or less <br /> T X E 8 T X E <br /> MAXIMLM ALLOWASLE 8.T-X-E LEVELS; so 50 50 .3 .3 1. 1. 1 4:A:\3 <br /> 0"Ple Resutt: ASOLINE 1000 100 71 o7 <br /> TPH <br /> AXI MUM ALLOWASLE TPH LEVELS (PPM) IESEL 10,000 1000 71007- <br /> OOTNOTES: ***If docurented soil and/or ground water contamination Is present, do not coaptete the teaching potential <br /> 'Ina lysis, (i.e., site is currently on UGT Contamination Listfor sell or ground water.) <br /> \1 If depth is � 5 ft. and < 25 ft., score 0 points'. If depth <,vS ft,, do not use tobte. <br /> \2 If Precipitation is * 40 inches, score 0 points. <br /> \3 Levels for SW E are not applicobte at a TPH concentration of 10 PPM (gaso(f2e) or 100 ppm_ (dieset). <br /> Vt. STAFF RECOWENDATION/CONCLUSION <br /> E1. EAr* STX It 6 or TPH Concentrations > Altowatite Levels Yes rs <br /> r* ' Sir' i! asrre <br /> 2 R if Yes, Refer to Site mitigation far Evatuation <br /> � <br /> Recow:w:n'd <br /> V11, REVIEW EVALUATION TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> R.ONCURWITH STAFF TRECOMMENOATION TI CLOSTUREES EOEFEERREEDTO SITE MITIGATION FOR EVALUATION CES 0 <br /> 1%.11 777] <br /> ATE REFERRED )ATE CLO"E LETTER MMAILEO <br /> AK Of <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />