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SAN JOAQUIN COUNTMBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH LNISION / <br />UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br />/ <br />-AME Of FACILITY !1 n ,/��J•A/ EEPS CODE S�6 <br />OO RE SS 37A0✓(,�f,c (r; -Lt - Sr(X+ ANK 109 <br />ANK SIZE �U p0�1 UEL TYPE FI.LX <br />11. GENERAL SITE HISTORY <br />permit <br />current? <br />as <br />o <br />o <br />ailed pret:ision test ? <br />ermit # <br />I <br />To <br />If <br />iFacility <br />10.25 <br />Status Code <br />es <br />ns repair done under inspection? <br />oc.Soil/GW <br />Cont <br />es <br />to <br />to <br />oar of <br />Tanks at <br />facility <br />PH•D <br />b/EDD <br />Be <br />of <br />Tanks(if <br />available) <br />long-term leakage <br />istance to Well( from from Tank <br />ype of Tank <br />teal <br />nown 1 <br />Fbrgl <br />ngl I <br />Dual <br />111. TANK HISTORY <br />:as Tank tested? <br />es <br />o <br />ailed pret:ision test ? <br />es <br />of/Year <br />To <br />If <br />yes, give date(s) <br />10.25 <br />Was a repair made to the tank system? as No f yes, what was repairedl <br />es <br />ns repair done under inspection? <br />es 40 <br />ere soil samples analyzed? <br />es <br />to <br />Irr <br />TXE <br />om <br />PN•G <br />PH•D <br />b/EDD <br />core <br />0 pts <br />'t <br />ondition <br />'s met <br />Type of failure/discharge <br />core <br />9 pts <br />if <br />condition <br />is met <br />atastrophic <br />long-term leakage <br />istance to Well( from from Tank <br />verfill <br />nown 1 <br />inimm Depth to groundwater from the Soil Sample (feet) <br />cher: <br />10 <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />oil Samples Received <br />es <br />o <br />epth to Ground Water <br />of/Year <br />verage Annual Precipitation <br />- <br />4 <br />10.25 <br />-Site Wells) <br />es <br />o <br />umber S Type <br />Irr <br />om <br />ub <br />S <br />C <br />0 <br />R <br />E <br />core <br />0 pts <br />'t <br />ondition <br />'s met <br />S <br />C <br />0 <br />R <br />E <br />core <br />9 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />core <br />pts <br />-f <br />onditlon <br />'s met <br />istance to Well( from from Tank <br />ft; ft; ft <br />Site Feature - Leaching Potential Analysis <br />inimm Depth to groundwater from the Soil Sample (feet) <br />>100 <br />1.100 <br />25.50\1 <br />ractures in subsurface (applies to foothills or mountain areas) <br />D <br />None <br />Unknown <br />resent <br />verage Annual Precipitation (inches) <br />xxxx <br /><10 <br />9 <br />10.25 <br />xxxxxxx <br />26.40\2 <br />an -Made conduits which increase vertical migration <br />f leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />resent <br />Inipue site features: Recharge area, coarse soil, nearby wells. <br />x/xxx <br />None <br />At least <br />ane <br />lore than <br />one <br />COLUMN TOTALS»>TOTAL POINTS <br />`J <br />ample Result: (B T X OR E) <br />����� �( /-1 <br />'_T�_ ok.) r r '_l <br />RANGE OF TOTAL POINTS <br />9 pts <br />or more <br />»7 <br />48 pts <br />GO pts or to <br />MAXIMLN ALLOWABLE D -T -X -E LEVELS (PPM) <br />G <br />1 <br />T <br />50 <br />X E <br />50 50 <br />3 T <br />.3 .3 <br />X. <br />1. <br />E <br />1. <br />NA\3 <br />Sample Result: <br />o � � TPN <br />Moo <br />SOLINE <br />ALLOWABLE TPN LEVELS (PPM) <br />fESEL <br />1000 <br />100 <br />10 <br />10,000 <br />1000 <br />100 <br />FOOTNOTES: •--If documented soil and/or ground water contamination is present, do not complete the leaching potential <br />analysis. (i.e., site is currently on LOT Contamination List for soil or ground water.) <br />\1 If depth is > 5 ft. and < 25 ft., score 0 points'. If depth 4=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 (diese L). <br />VI. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX 8 E or TPM Concentrations > Allowable Levels Yes o <br />2. Recommerd Site Closure as o If Yes, Refer to Site Mitigation for Evaluation <br />`III. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR ENIOR <br />ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ESO EFERRED TO SITE MITIGATION FOR EVALUATION <br />ATE REFERRE: ATE CLOSURE LETTER MAILED <br />,w vPVA = <br />t'iA. O, i I <br />FN 23 8r (UCTWKSHT+\.i9U <br />i.1 S)o <br />