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SAN JOACUIN COL' PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL' IVISION bb <br /> 1• <br /> L. WORKSHEET FOR SITE CLOSURE EVALUATION �. ATE //� C c <br /> AME OF FACILITY • j �('h.bllP/1N ll it-r/Y WEEPS CODE <br /> DRESS �-/- S�or�Rc w AN ID 9 <br /> TANK SIZE C)OC) UEL TYPE 42� <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? as o emit C acility Status Code OC.Soil/GW Cont es o <br /> d <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank teal Fbrgl I Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested? as I IN01 ailed precision test 7 as o If yes, give date(s) <br /> Jas a repair made to the tart system? es No f yes, what was repairedr <br /> as repair done under inspection? es o ere soil samples anal yzed7 as o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term Leakage verfitl ncwn 1 10 <br /> cher: <br /> 1V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es I IHOI epth to Ground Water �L� of/Year �rZ verage Annual Precipitation = < 0-25 <br /> •Site WeLL(s) es o umber 8 Type Irr an <br /> S core S core S [ore <br /> istance to Well(:) from Tank ft; ft; ft C 10 pts C 9 Pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R ordition <br /> W. Site Feature . Leaching Potential Analysis E is met E is met E is met <br /> inirmm Depth to groundwater from the Soil Sample (feet) >100 1-100 S 25-5011 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxx 26-4012 <br /> an-Made corduits which increase vertical migration - <br /> f leachate (i.e., septic systems, water wells, ponds) Nano j Unknown resent <br /> nique site features: Recharge area, coarse soil, nearby wells. �, At leas 4ore than <br /> xxxx None 7 one one <br /> COLUMN TOTALS»>TOTAL POINTS . 3lG ♦ If <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pt 40 pts or less <br /> B 1 T X E 8 T X E <br /> MAXIMUM ALLOWABLE B-T-X•E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA,LS <br /> Sample Result: SOLINE 1000 100 10 <br /> ** IMUM ALLOWABLE TPM LEVELS (PPM) <br /> G(0 QP H TPH t, IESEL 10,000 1000 100 <br /> FOOTNOTES: '==If documented soil and/or grand 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 /> L If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> L If precipitation is > 40 inches, score 0 points. <br /> L Levels for BTXSE are not applicable at a TAN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX d E or TPH Cancentrati,orrs > Allowable Levels Yes o <br /> 2. Recommend Site Closure as Id !Jo If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE IfES I EFERRED TO SITE MITIGATION FOR EVALUATION ES I 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />