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SAN JOAGUIN COUNTY 7 C HEALTH SERVICES/ENVIRCNMENTAL HEALTH 01' ON P <br /> UGST W&r SHEET FOR SITE CLOSURE EVALUATION �.. ATE ) <br /> >-E OF FACILITY tl)� /J�� / EEPS CODE <br /> )DRESS TAA .c ANK <br /> SNK SI2E �5y UEL TYPE <br /> GENERAL SITE HISTORY <br /> s permit current? as o ermit 3 acility Status Code oe.Soil/GW Cont as to <br /> under of Tanks at facility ge of Tanks(if available) ype of Tank teel IFbrgl ngl I Dual <br /> . TANK HISTORY <br /> as Tank tested? es o ailed precision test ? Ifas o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> ns repair done under inspection7 ea o ere soil samples analyzed? I as to I TXE I PH-G PH-D b/EDD <br /> ype of faiture/discharge atastrophic long-term leakage i 13verfilt I noun I cher: <br /> REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT 'ATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received Ifes I o eoth to Ground 'water I of/Year verage Arcual Precipitation 4 10-25 <br /> n-Site vel L(s) as o umber 3 Type Irr pm b <br /> S coreS core 5 core <br /> istance to 'well(s) from Tank ft; ft; ft 0 pts C pts C 5 pts <br /> 0 'f 0 if 0 if <br /> R ondi tion R condition R ondi tion <br /> Site Feature - Leaching Potential Analysis _ s met E is met E is met <br /> iinimum 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 rresent <br /> •verage Arcual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxx 26-40\2 <br /> ,nn-Made Conduits which increase vertical migration <br /> )f leachate (i.e., septic system, water wells, ponds) None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxx Now one p� one <br /> COLUMN TOTALS»)TOTAL POINTS • c, ' tT Al <br /> Sample Result: (3 T X OR E) RANGE OF TOTAL POINTS 9 pts or moreI .1 Aa pts 0 pts or Less <br /> UU MAXIMUM ALLOWABLE O-T-X•E LEVELS (PPM) 1 50 50 1 50 .3 .3 1. 1. NA\3 <br /> Sample Result: SOLINE 1000 100 10 <br /> C j0 (-e^ TPN Com' AxIMUM ALLOWABLE TPN LEVELS (PPM) <br /> lESEL 10,000 1000 100 <br /> 'COtNOT'cS: ...If documented 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., score 0 points'. If depth <=5 ft., do not use table. <br /> \2 If precipitation is > AO inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> STAFF RECOfMENDATION/CCNCLUS(09 <br /> 1. Are 3TX & E or TPN Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site closure es of 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 IfES 0 EFERREO TO SITE MITIGATION FOR EVALUATION ES JO <br /> ATE RE FERREO �.A'e CLOAIRE LETTER MAILED i / <br /> F AL'UAi,? <br /> F <br /> [Y 23 <br />