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SAN JOAOUIN -.S�vUBLIC HEALTH SERVICES/ENVIRONMENTAL H'. 1, /ISION <br /> 1• Uwf WORKSH ECT IOR SITE CLOSURE EVALUATION AiE <br /> AHE OF FACILITY zzz��1 0WEEPS CODE <br /> DDRESS l (/ /// r ANK ID X ? 0 <br /> TANK SIZE ` UEL TYPE i V <br /> It. GENERAL SITE HISTORY <br /> Is permit current7 as o ermit # - acility Status Cade g oc.Soil/GW C t eso <br /> umber of Tanks at facility ge of Tanks(if available) �'� ype of Tank teal brgl ngl Dual <br /> 111. TANK HISTORY 14 Iq <br /> as Tank tested? as VINo ailed precis!7 test ? es o If yes, give date(s) 0///p /n; / /5 / 7 <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es o ere soil samples analyzed? as o TXE PH-G PH-0 b/EDS <br /> ype of failure/discharge atastrophi[ long-term leakage verfitl known ther: i If1 IC <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o ep[h to Ground Water �Q. of/Year &" verage Arnual Precipitation = 4 0-25 <br /> -Site Well(s) es o umber 8 Type Irr om ub <br /> S core S core S core <br /> istance to Wells) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 if 0 if 0 f <br /> R andi tion R audition R ordition <br /> Site Feature - Leaching Potential Analysis E is met E is met E 's met <br /> inimum Depth to groundwater from the Soil Sample (feet)3O —5009 5 1?100 1-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) ) Q More Unknown resent <br /> vcrage Annual Precipitation (inches) xxxux <10 9 10-25 Kxxxxxx 26.40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water welts, pords) None Unknown resent <br /> ique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> Jxxxx None one J one <br /> COLUMN TOTALS»>TOTAL POINTS l O * J Q + / 38 <br /> Sample Result: (BT X OR E) RANGE OF TOTAL POINTS F9 pts or more 41 48 pts 40 pts or less <br /> 4Tv,a -r= eat <br /> •117 B T X E B T <br /> /-"T"c'� X d• 1 7 MAXIMUM ALLOWABLE B-T•X-E LEVELS (PPM) 1 50 50 50 <br /> ample Result. <br /> r <br /> INE 1000 100 10 <br /> LANA. IS=6-5c)� �AXIMIJM ALLOWABLE TPH LEVELS (PPM) <br /> .sg;p T H L 10,000 1000 100 <br /> DOTHOTES: ...If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for sail or grovel water.) <br /> \1 If depth 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 /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECO MENOAT ION/CONCLUSION <br /> This s+fe• io o•ptn �ay1^�MWn�C uAJ <br /> 1. Are BTX B. E or TPH Concentrations > Allowable Levels YesIV o -5-IF ( " T <br /> 2. Recommend Site Closure as o If Yes, Refer to Site Mitigation for Evaluation �*��pL�y�(�}��/p.'l���.Ca'V 07ven <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR AXA +"- _ �� <br /> yy-- # <br /> ICONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 I EFERRED TO SITE MITIGATION FOR EVALUATION rs <br /> 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> TAME OF <br /> :VALUATOR <br /> EN 23 80 (UGTWKSHT)\5/90 <br />