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SAN JOAQUIN Y PUSLIC HEALTH SERVICES/ENVIRONMENTAL HEAL 1VISION <br /> 1. UGS7 WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AE OF FACIL7Y EES cooe <br /> 00RE a ANK 10 N <br /> ' W, ANK SIZE IrL TYPE <br /> 11. GENERAL SITE HISTORY <br /> t Orsi current T wrsi sci t i ty Stsus C Sri t r Cont05 <br /> sr <br /> r f TsoaRs st fseiti e Trtif ssitslte) Txrair teat drSt rt Duct <br /> 111. TANK HISTORY <br /> a Tank test d7 es ' sited predisi test T es If yes, give date(s) � <br /> s s repair t the tsri cyst T es N f des: whit was it <br /> As repair tyzed7 as 40 TXE PH-G PHx d ECS <br /> t Ns'tueddisetesr stssrric l S�terr tLsa�e er 's't t n n torr; <br /> t . REMOVAL, HISTORY (ATTACH INSPECTION REPORT fCA SITE DETAILS/COLLECT DATA fOR LEACHING POTENTIAL ANALYSIS) <br /> of t Samptes Received es 0 epth to Oroundhater eftYerrr <br /> verage Annuat Prcipittierr 't - S <br /> -Site weti(s) as r 9 Type irr uta <br /> S core S core S core <br /> istance to tlett(s) from Tank ft; ft; ft C tI pts C pts C pts <br /> 0 if C f <br /> It omditfoo A ondition R ondition <br /> Site Feature - Leaching Potemtiat Analysis E s t E= is met E s met <br /> imimum Depth 'to groundwater from the Soot Soapte'(feet) >1 1-1 � 5-50\1 <br /> rsctures in subsurface (applies to foothitis or motntain areas) None Unknown resent <br /> vtrage Aroual Precipitation (inches) xxxxx 'CIO p 10-25 xxxxxxx -40\2 <br /> nrt-Made .10nduits which Increase vertical migration <br /> f leachate (i.e., septic systwS, water wells, ) None Unknown resent <br /> 1nique site features: Recharge ares, coarse snit, nearby welts. At least ire thin <br /> xxxx None one <br /> COLU14N TOTALS>>>TOTAL POINTS <br /> ample Result.' R T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> II T X E S X <br /> MAX ALLOWABLE 0,T-X-E LEVELS (RPM) so 50 50 3 .5 1. 1. HA15 <br /> ample Resuttr' RECLINE 1000 100 10 <br /> AXiMUM ALLOWAaLE TPH LEVELS (RPM) <br /> T it'; IESEL 10,000 100 100 ` <br /> 7N TES: ***If documented soil ,tor grovnd water contamination is present, do net complete the leaching potential <br /> analysis. 0.e., site Is currently on LIG7 Contamination List for sail or grotaxi water.) <br /> \1 It depth;is 5_ft. and 4 25 ft., scoro 0 points'. If depth -5 ft., do not Use table, <br /> \2 If precipitation is ), 40 inches, score C points. <br /> '3 Levels for STX&E are not applicable at a 7PH concentration of 1 (Sas ire) or 100 di eel). <br /> Vt. STAFFRECOMMENDATION/CONCLUSION <br /> E <br /> ESTXE ear TH Crtcntrstic Allowable: Covets- Yes sSite Closure es o If Yes, Refer to Site Mitisati for evaluation <br /> V11. REVIEW EVALUATION TO SE COMPLETED ST A SUPERVISOR/SENIOR <br /> .ONCUR'WITH STAFF RECOMMENDATION FOR CLOSURE 'ES EFRRREC TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED ATE CLOSURE LETTER MAILED J / <br /> AME O <br /> 'VALUATOR <br /> EN 23 SC tlGTWKSHT)\5/ <br /> EH 29 80 <br />