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SAN JOAQUIN CC, -Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL 1IVISION <br /> 1. �: WORKSHEET FOR SITE CLOSUREEVALUATION ,� ATE <br /> AME OF FACILITY S(- ��, 4 ,V CM ✓2/L c P WEEPS CODE00 <br /> DRESS 7 0 i � ANK ID # pt45 G( <br /> UEL TYPE Oylf el <br /> II. GENERAL SI E HISTORY 'U <br /> rr <br /> Is permit current? es I o ermit # - acility Status Code oc.SoiL/GW Cmc es o <br /> a <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank teel Fbrgl ngl Dual <br /> :I1. TANK HISTORY <br /> as Tank tested7 as o ailed precision test 7 as o If yes, give date(s) <br /> as a repair made to the tank system? 1YaS No f yes, what was repaire?1 <br /> as repair done under inspection? es o ere soil samples analyxed7 es o I TXE I PH-G I PH-D b/EDB <br /> Type of failure/discharge atastrophic lmg-term Leakage verfill nown I lother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water y' of/Year �- ; verage Annual Precipitation = 4 0-25 <br /> -Site Wett(s) IYes o umber 8 Type 1rr om <br /> S Score S core S core <br /> istance to WeIL(s) from Tank ft; ft; ft C 10 pts C pts C pts <br /> 0 if 0 if 0 t <br /> R Condition R ondition R oMition <br /> V. Site Fea cure - Leaching Potential Analysis E is met E is met Es mac <br /> inimun Depth to groundwater from the Soil Sample (feet) >100 1-100 - 25-50L <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Dresenc <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxx 26-40L <br /> en-Made conduits which increase vertical migration <br /> f Leachate (i.e., septic systems, water welts, ponds) None -) Unknown Present <br /> pique site features: Recharge area, coarse soil, nearby wells. At Least ore than <br /> xxxx None we one <br /> 7 ' <br /> COLUMN TOTALS»>TOTAL POINTS * 'Y' - �k7 <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more Al - 48 pts 4 p[s or s <br /> PP' B T X E B T X. E <br /> MA%IMIM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> ample Result: SOLINE 1000 100 10 <br /> IMUM ALLOWABLE TPH LEVELS (PPM) <br /> eLl � TPN ' 17 IESEL 10,000 1000 100 <br /> OOTNO ES: --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 rot use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPM concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMENDATION/CONCLUSION ' <br /> 1. Are BT% b E or TPH Concentrati ors > Allowable Levels Yes o <br /> 2. Recommend Site Closure es IL4o I 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 ES 0 I EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />