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SAN JOAOUIN CCU PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALP' 'VISION <br /> I. Uw..._ WORKSHEET FOR SITE CLOSURE EVALUATION) ATE <br /> nME OF FACILITY W kiST- 1 ,.r, a Fa e C� _ S EEPS CODE O6 <br /> OOC <br /> RESS �' _ ANK t0 <br /> TANK SIZE QW WELL_TYPE <br /> !I. GENERAL SITE HISTORY <br /> Is permit current? es o ermit p - acitity Status Code oc.;Qit/GW Cont es o <br /> unber of Tanks at (acitity ge of Tanks(ff availabLe) uNk ype of lank Ce brgl Dual <br /> Ill. TANK HISTORY <br /> ns Tank tested? es v1H. <br /> ailed precision test 7 Ires o If yes, give <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspectfon? es go ere soil samples analyzed? as o TXE PH-G PH-D b/E08 <br /> ype of failure/discharge atastrophic long-term leakage ver <br /> I known Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> gistance <br /> Received es o epth to Ground Water 3 S of/Year ,, ; S6 verage Annual Precipitation < 0-25 <br /> es or 8 Type Irran ubS core S core S core <br /> et((s) from Tank ft; ft; ft C 10 pts C 91 pts C ; pts <br /> O if O if O 'f <br /> R ondition R condition A ondition <br /> J. Site Feature - Leaching Potential Analysis E is met E is met E -s met <br /> inimtm Depth to grourdwater from the Soil Sample (feet) >100 1-100 S 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> verage Annual Precipitation (inches) xxxx <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, ponds) None 9 Unknown resent <br /> ique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxx None q one one <br /> COLUMN TOTALS»>TOTAL POINTS r <br /> a le Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> ND <br /> B T % E B T % E <br /> NA <br /> XZ ALLOWABLE B-T-X-E LEVELS (PPM) 1 150 50 50 .3 .3 1. 1. HA\3 <br /> anpte Result: ASOLINE 1000 100 10 <br /> 11 AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> N D <br /> TPH-6, IE SEL 10,000 7000 700 <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 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 BTXBE are not applicable at a TPN concentration of 10 ppn (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECON4IENDAT ION/CONCLUSION <br /> 1. Are BTX 6, E or TPH Concentrations > Altowabte Levels Yes o <br /> I2. Recommend Site Closure �es I�a I I+If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> A1EREFERRED / / ATE CLOSURE LETTER MAILED � V j <br /> LANE OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />