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;y <br /> SAN JOAQUIN PUBLIC HEALTH SERVICES/ENVIRONMENTAL IfEAL' VIS1ON <br /> t: UST WRKSKET FOR SITE CLOSURE EVALUATION ATE <br /> AME Of FACILITY EAS CODE <br /> CES ANK'1C N <br /> `' ,, .ANK SIZE 07L TYPE <br /> 1 � ErrERAL SITE MURY <br /> S rri carr` tT s rri s 'i t i ty tstcas C' i I/ttt cont es 0 <br /> r TsrtdcK €city Se + Esf of sysitble) ra Tse teat brt Nt oust <br /> t f. TANK HISTORY <br /> Tame test 3 silk prisi test T If yes, givedate(s) l 1 <br /> s s repair de t the is cyst 'T N f # + repaired? <br /> ns repair r ins et T ere sraat lis err l"ytedY es 0 T E Paf_C rr•Q tr/SCS <br /> Re f fsi3�rrtrishMrge stsstr� i t g�t IksrJe erfilt rsi:ra r� thr» <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION RETORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> sat S&VIOS R verage Armal Precipitation 4 0-25 <br /> -Site Weltts) r S err <br /> S tore S core S core <br /> istamce to we C C pts C pts C pts <br /> if C if <br /> Site Fesfeature Leaching PtentPotential, A R it# ' R iti Lysis E s met E is ' t E s t <br /> iniguft Depth to groundwater from the Scat Ssmpte '(feet) >100 1.1Cti 2 5C\ <br /> rears in sUbSurface (apptles to foothilts or mountain areas)' None <br /> rte res <br /> ersge Annual Precipitation (inches) xxxxx '10 9 10-25 s x -40\2 <br /> rrn-Made conduits which increase tic t migration <br /> f teschste (ire., septic system, water wells, ) gone Unknown resent' <br /> ins' re Site features: Recharge area, sparse s its nearby welts. At test ore than <br /> xxxx None one onc <br /> COLUMN TCTALS>>>TCTAL POINTS' <br /> ample Result: IS T X OR E RANGE LIF TOTAL POINTS 9 pts or vore 41 - 48 pts 45 pts or tens <br /> 'k X <br /> MAXIMUM ALLOWABLE -T^3t-E'LEVELS s(PPM) 1 50 55 50> 1. 1„ NA\3 <br /> ample Resutt. ASCLINE 1000 100 10 <br /> AXIMUM ALLOWABLE T H LEVELS (PPM) <br /> TEN IE EL 10,000 1300 100 <br /> tTNOTE . ***If teti snit and/or grownd water contamination is present, do not ccoplete the teaching potential <br /> a ranaty$fs. (i.e*, Site is currently on UGT Contamination List for suit or ground crater.)` <br /> t If depth is 5 ft. and 4 25 ft., score TIints* If depth =S ft., edea not use table, <br /> \2 If precipitation is 40 inches, score C paints. <br /> � � Levees far STSE are t s tirabte s s TRN t entrarti f 1i) Cgssaata ) car 1r . Itiiset)< <br /> Vt. STAFF REC ENIIATICN/CONCLUSION <br /> E <br /> Aro ST S E or TPtf Concentrations Alt bte Levels Yes a <br /> R SatR Ctiastare s If Yes, Refer to Site mitigation far E stared <br /> il< REVIEW EVALUATI TO BE CCMPLETEQ BY A SUPERVISOR/SENIOR <br /> CrCL+R tJYTti STAFF REC ffiENQA tLrN FtSR CLOSURE E C EFE REQ TOsSITE MITIGATION FOR EVALUATION ES' C <br /> AiE RE:FERREQ a" / ATE CLtT i E LETTER MAILED / <br /> ASE CFI <br /> VALLiAT <br /> Etc 23 60 (UCt KSRT)t5/9C <br /> H 29 80 <br />