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SAN JOAQUIN COUNTY P C HEALTH SERVICES/ENVIRONMENTAL HEALTH DI' DN <br /> UGST WLOWSHEET FOR SITE CLOSURE EVALUATION ATE 74 ` <br /> "E OF FACILITY > G� <br /> / EEPS CODE <br /> ' <br />)ORESS />)� J W' L ZO62 ANK 10 s It'03 , b <br /> ANK SIZEI IF <br /> UEL T PE ZZ�G - /�C) �b''✓ <br /> GENERAL SITE HISTORY <br /> s permit current? es oermit 0 anility Status Code oc.Soil/GW Cont es !o <br /> untxer of Tanks at facility Fie <br /> of Tanks<if available) IType of Tank tee! I IF <br /> brgl ngl I Dual <br /> TANK HISTORY <br />.is Tank tested? as IFailed precision test ? Ifes o If yes, give date(s) <br /> as a repair made to the tank system? es No I f yes, what was repairedr <br /> as repair done under inspection7 es o ere soil samples analyzed? es to TXE PH-G PH-D b/E00 <br /> ype of failure/discharge atastrophic long-term Leakage verfill I sown I io <br /> cher. <br /> REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es 0 epch to Ground water of/Year verage Annual Precipitation = 4 10-25 <br />-•Site uctt(s) es o umber 2 Type Irr cm b <br /> S core S Score S care <br /> istance to Well(s) from Tank ft; £t; ft C 0 pts C 9 pts C Pts <br /> 0 'f O if 0 'f <br /> i onon ditiR conditi on 3 ondi tion <br /> Site Feature - Leaching Potential Analysis C �is met E is met E is met <br /> linimum Depth to groundwater from the Soil Sample (!eet) >100 1-100 25.50\1 <br /> actures in suosurface (applies to foothills or mountain areas) O None Unknownree enc <br />.verage Arcual Precipitation (inches) xxxx <10 9 10-25 Kxxxxxx 26-60\2 <br />'nn-made conduits which increase vertical migration Q <br /> if Leachate 0,e., septic systems, water wells, ponds) None ( Unknown !!!'''resent <br /> Inipue site features: Recharge area, coarse soil, nearby wells. At least pore than <br /> xxxx None One I one <br /> COLUMN TOTALS»'TOTAL POINTS _F/7) 7, (Jp <br /> I <br /> Sample Result: IS T X OR E) RANGE OF TOTAL POINTS 9 pts or more/ 1 .1 48 pt LO pcs or Less <br /> 'u 1 T X E 3 --I E <br /> 1' MAXIMUM ALLOWABLE O-T-X•E LEVELS (PPM) 1 50 50 50 .3 .3 1, 1. NA\3 <br />;amble Result: SOLINE 1000 100 10 <br /> IMUM ALLOWABLE TPH LEVELS (PPM) <br /> M TPX L IESEL 10,000 1000 100 <br />'COTHOTES: •='I docunentod soil and/or ground water contamination is present, do not complete the Leaching potential <br /> analysis. (i.e., site is currently an UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., scare 0 points'. If depth <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for STXBE are not applicable at a TPN concentration of 10 pan (gasoline) or 100 ppm (diesel). <br />. STAFF RECOMEHOATION/CONCLUSION <br /> 1. Are 3TX 3 E or TPN Concentrations > Allowable levels Ycs o <br /> 2. Recommend Site Closure es o if Yes, Refer to Site Mitigation for Evaluation <br /> I. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 1110 <br /> EFERRED TO SITE MITIGATION FOR EVALUATION �ES NO <br /> i <br /> ATE REFERRER. YA'E CLOSURE LETTER !AILED <br /> l <br /> FL L'JAi Ge <br /> .H 3 L_ pr �� <br /> 2 <br />