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SAN JOAOUIN COU••� LIC HEALTH SERVICES/ENVIRONMENTAL HEALTI ION <br /> UG r-M9KSBEET FOR SITE CLOSURE EVALUATION "�� ATE <br /> nnE Of FACILITY EPS CODE�y � L <br /> OOR£SS ANK ID Y 'Z <br /> InNK 512E UEL <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es o ermit A - acility Status Code oc.Soil/Gu Conc es o <br /> unbar of Tanks at facility Be of Tanks(if available) ' of Tank teel IVIFbrgt rgl Dual <br /> Ill. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o If yes, give dates) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> 'as repair done under inspection7 esa ere soft samples analyzed? as o TXE PH-G PH-D b/EDB <br /> type of failure/discharge atastrophic long-term leakage verfill nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/CO LECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received as c epth to Ground Yater of/Year verage Arnual Precipitation N= 11 <br /> 4 11 0-25 <br /> )n-Site Well(s) es o X urber 8 Type Irr om ub <br /> S Score S Score S 5core <br /> istance to Yells) frau Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R zonditiort R condition R ondition <br /> J. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimua Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) KXXxxX <10 KXXXXXX 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least are than <br /> xxxx Hone one one <br /> COLUMN TOTALS>>>TOTAL POINTS t <br /> amJpj�e Resul c. (B T OR E - RANGE OF TOTAL POINTS 9 Acs or more 41 48 pts 40 pts or less <br /> 'j",11 A rep /!�_U///4 B T X E B T X E <br /> W�eg�~" „"% MAXIMUM ALLOWABLE B•T•X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> unple Result: ASOLINE 1000 100 10 <br /> AX)FUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTES: ...If documented soft and/or ground water contamination is present, do not comptete the Leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil 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 STXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> Vt. STAFF RECCFMENDAT ION/CCNCLUS ION <br /> 1. Are 3TX $ E or TPH Concentration > AllowabLe Levels Yes <br /> 2. Recommerd Site Closure es o If Yes, Refer to Site Mitigation for EvaluationJ. ov--J <br /> VII_ REVIEW EVALUATION - TO BE CCMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCJR WITH STAFF RE[CHMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> DATE REFERRED / / ATE CLOSURE LETTER MAILED ¢ <br /> TAME OF <br /> CH 23 90 (UGTYKSHT)\5/90 <br />