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SAN JOAWIN,..,NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H H DIVISION <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION `•� ATE /) <br /> AME OF FACILITY2,t2 K�; 4� I rlickih WEEPS CODE a 3 <br /> DDRESS /✓ ('� �• tLY ANK ID N a <br /> TANK SIZE JOS UEL TYPE I Rf _ ah/1t <br /> II. GENERAL SITE HISTORY <br /> Is permit current? eso W Cont ermit N acility Status Code oc.Soil/Ges to <br /> umber of Tanks at facility he of Tanks(if available) IT <br /> ype of Tank teel Fbrgl I Isn9i Dual <br /> III. TANK HISTORY <br /> Was Tank tested? as o ailed precision test ? es o I If yes, give date(s) / / / / <br /> Was a repair made to the tank #atastrophic <br /> as No f yes, what was repaired? <br /> ns repair done under inspectiaso ere soil samples analyzed? es to TXE PH-G PH-D _L/EDB <br /> Type of failure/discharge long-term leakage verfill nknown cher: <br /> TV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> -oil Samples Received as 1/ o epth to Ground Water ab of/Year �(,� 6 verage AmuaI Precipitation = 4 10-25 <br /> )n-Site Wells) as oF Ilumber S Type Irr am I ub <br /> 5 Score S Score S Score <br /> istance to Welt(s) from Tank ft; ft; ft - C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondition <br /> v. Site Feature . Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) ; t0'I, >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) 0 None Unknown resent <br /> average Annual Precipitation (inches) KXXXXX <10 9 10.25 xxxxxxx 26-40\2 <br /> nn-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) rL2 None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS do a + Q • O 29 <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> G T X E B T % E <br /> 00+11 PIRM MAXIMUM ALLOWABLE B•T•X•E LEVELS (PPM) 1 50 50 50 .3 I. <br /> 1. 1. NA\3 <br /> -anpte Result: ASOLINE 1000 100 10 <br /> A%IMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently on UST Contamination List for soil or ground 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 RECOMMENDATION/CONCLUSION <br /> a/ <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> L2. Recommend Site Closure lY as I ITO I Ik If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE 'ES '0 EFERRED TO SITE MITIGATION FOR EVALUATION ES JO <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME Of <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />