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SAN JOAOUIN CCU' 'ELIC HEALTH SERVICE5/ENVIRONME4TAL HEALTI n SIGN <br /> I. Ud� ORKSHEET FOR SITE CLOSURE EVALUATION ATE 6 <br /> nME OF FACILITY -� EPS CODE �S z <br /> nORE SS c CO O d//S rx� ESCIY/ a at ANK 10 Y - r2 <br /> InNK SIZE 3 ADO UEL TYPE SP <br /> II. GENERAL SITE HISTORY <br /> Is permit current7 as o ermit # acility Status Code 150 IDoc.Soil/GW Cant es o <br /> unber of Tanks at facility or <br /> Be of Tanks(if available) 1-16, <br /> 6 MYpe of Tank teal brgl ngl Dual <br /> 111. TANK HISTORY / <br /> ms Tank tested? as o ailed precision test 7 es o (� 1f yes, give date(s) <br /> as a repair made to the tank system? as No f yes, what was repaired? <br /> as repair done under inspection7 es Umere soil samples analyzed? es o TXE PH-G PH-0 b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown 1 10 <br /> ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water O of/Tear Sjo verage Arnual Precipitation = 4 0-25 <br /> ri <br /> Site Well(s) es o user 8 Type Irr am ubS core S core S coretance to Wells) from Tank ft; ft; P ft C 0 Pts C Pts C Pts <br /> 0 if O if O f <br /> R ondition R ondition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimuo Depth to groundwater from the Soil Sample ?feet) O >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> %verage Annual Precipitation (inches) xxxxx <10 9 10-25 Kxxxxxx 26.40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, panels) More Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least ) are than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS (' + .g 7 + <br /> ample Result: (8 T X OR E) RANGE OF TOTAL POINTS P pts or more 41 - 48 pts 40 pts or less <br /> 8 T X E 8 T X E <br /> lel <br /> I MAXIMUM ALLOWABLE 8-T•X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> ample Result: ASOLINE 1000 100 10 <br /> A%IMUH ALLOWABLE TPH LEVELS (PPM) <br /> n TPN IESEL 10,000 1000 100 <br /> OOTHOTES: ...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 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 MILE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECCH4ENDATION/CONCLUSION <br /> 1. Are BTX S. E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigatian for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> -ONCUR WITH STAFF RECCNME40ATION FOR CLOSURE lyES I I 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 L/ <br /> ATE REFERRED / 1 f" / ATE CLOSURE LETTER MAILED JAME <br /> :VALUATOR OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5 90 <br />