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SAN JOAQUIN C PUBLIC HEALTH SER VICES/ENVIRONNENTAL REALooatlit SION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME Of FACILiT1 ees CODE <br /> DRESS y ANIS 10 <br /> 0K SIZE UE TYPE <br /> If. CEWERAL SITE HIS ORY <br /> acility Status Code .Soil/GACent <br /> 9!9=kEgs oEfTankEs(if avaEitabteT) f gype KofTank jateet <br /> it I. TANK HISTORY <br /> is Tank test <br /> If yes, give date(s) <br /> as a repair repa Ir <br /> AS repair lyzed? es 10 TXE PH-G <br /> Prt.0 WEDS <br /> IV. PEMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ,oi( Saiopies Received as 0 epth to Ground Wateref/Year l Precipitation 4 0-25 <br /> 461 Y6 i verage Annua <br /> -Site Wetl(s) es )( o umber & T 1rr — up S core S core S or <br /> fists to Welt(s) from Tank _f t; ft; ft C 0 Pts C pts = Pts <br /> 0f 0 if 0 <br /> A orAlition R ondition A ondition <br /> Site Feature - Leaching Potential Analysis f a met E is met E <br /> inims.a Depth to groundwater from the Soit Sampte (feet) >100 J-100 � 25 SACT <br /> ractures in subsurface to tis to foothitts or mountain areas) None <br /> vera ge Annual Precipitation (inches) xxxxx '410 9 10-25 xx 26-40\2 <br /> i an <br /> -Made conduits which increase vertioat migration <br /> I tea hate 0.oR, septic systems, water Nails, ponds) $one Unknown resent <br /> Inique site features: Recharge area, coarse snit, nearby weits. At least ore than <br /> s None one one <br /> COLUMN TOTALS NOTAL POINTS <br /> anple Resutt: IS T X OR E) RANGE Of TOTAL POINTS 9 pts or more 41 48 pts 40 pts or Less <br /> 7– )( <br /> 8 1 X E 8 T X E <br /> MAXIMUM ALLOWABLE 3-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. (NA\,3) <br /> an to Result; ASOLINE 1000 100 10 <br /> 100 TPH AXIMUN ALLOWABLE TFA LEVELS (PPM) IESEL 10,000 1000 100�f <br /> OOTNOTESt ***If documented snit and/or ground water contamination is present, do not cohptete the teaching potentiat <br /> smatysis. (i.e., site is currentty on UOT Contamination List-for coat or growsd water.) <br /> \1 If depth is ), 5 ft. and < 25 ft., store 0 points. If depth <=5 ft., do not use table, <br /> Vt. STAFF RECOMMENDATI ON/CONCLUS ION <br /> 1. Are BTX 4 E or TSN Concentrations > Attc�wab�IoLeveti! <br /> 0 <br /> Yes <br /> A to <br /> TX 4 V� <br /> Re E <br /> Cm IN: i If <br /> 2. Recommend 0 If Yes, Refer to Site Mitigation for Eva GUation <br /> Ez' <br /> VTIREVIEW EVALUATION - TO BEi C014PLETED BY A SUPER VISORISENI,R <br /> .0HCUR WITH STAFF RECOMMEN OATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED ATE CLOSURE LETTER MAILE <br /> AME OF <br /> .VALUATOR <br /> EN 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />