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SAN 4OAQUIN 04owY PUBLIC REALTH SERV ICESIENVIROMMENTAL HEAL*4041VUSION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME Of FACILI EPS CODE <br /> 00RESS ANN 10 <br /> ARK SIZE LCL TYPE <br /> 11. CENERAL SITE HISTORY <br /> Cont es 0 <br /> rVI Duat <br /> 111. TANK HISTORY <br /> 'as Tank testa es a ail re isi test a f yes, 91 Ve date(s) <br /> as a repair t tie ara sat N f Mesa mat repaired? <br /> As repair yzed? es I THE P1s.G P1190 tat ECS <br /> IV. REMOVAL 141STORY (ATTACH IRSPECTIOX REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> i <br /> oil S ' les A 3 verage A Pre0pitation 4 0-25 <br /> -Site Well($ <br /> S core S core S core <br /> istance to we C 0 pts C pts C pts <br /> 0f 0 If 0 <br /> R ondition R ondition Ritidn <br /> Site Festuro - Leaching Pstentist Analysis E s m4t E is met E <br /> imimum Depth to grour4water, from the Soit Simpte (feet) >100 1.1 <br /> ractures In subsurface (applies to foothills or muntwin areas) <br /> verege Annual Precipitation (imhes) xxxx <10 9 10.25 xxxxxxx 26-40\2 <br /> an <br /> -1fade conduits which increase vertical migration <br /> I teachate (i.e„ septic systcos, water Watts, Porch;) None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wetts. At least ore than <br /> xxxxx X" one one <br /> COLUMN TOTALS—TOTAL POINTS 16) + + <br /> ampte Rtsutt: (0 T X OR E) RANGE OF TOTAL POINTS pts or more 41 48 pts 40 pts or Ess <br /> 8 T X E 8 T X E <br /> MAXIMUM ALLOWABLE 3-T-X-E LEVELS (PPM) 1 50 50 50 .3 3 1 1. 4.13Aft <br /> ampte Result: ASOL IRE 1000 100 10 <br /> AAI KM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1 0 100 <br /> Cm <br /> OOTROTES* If docuownted soft and/or 9rcund water contamination is present, do not comptete the teaching pot tial <br /> anatteis. (i.e., site is currently on LIST Contamination List-for spit or grou'd water.) <br /> \1 If dvpth 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 /> a TPH concentratfon of 10 ppm (qasotise) or 100 idr ser(,, <br /> Vf> STAFF RECOWENDAT I ON/CONCLUS ION <br /> 2a ra `Sate sure ;es +� If YDS, Refer t ire flitgatit far Etuai <br /> Vll. REVIEW EVALUATION - TO BE C04PLETED BY A SUPERVISOR/SENTOR <br /> .ONCUR WITH STAFF RECOMMENDATION FCR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED P ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VALUATOR <br /> Eli 23 80 (UGTWKS1iT)\5/90 <br /> ZH 29 80 <br />