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SAN JOAQUIN NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA H DIVISION q <br /> 1. LOST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY WEEPS CODE <br /> DDRESS 3 fG O C ANK ID p <br /> • O <br /> TANK SIZE UEL TYPE <br /> It. GENERAL SITE H ORY <br /> ** <br /> .s permit current? es o ermit k I acility Status Code oc.Sol[/GW Cont es o <br /> umber of Tanks at facility Be of Tanks(if available) ype of Tank Leel Fbrgl ngl I Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test 7 es o If yes, give date(s) <br /> Was a repair made to the tank system? IYes No I 11f yes, what was repaired? <br /> as repair done under inspecti on7 es o ere soil samples analyzed? es I )o I TXE PH-G I PH-D I b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> soil Samples Received as x o epth to Ground Water of/Year l ; ig lAverage AmuaI Precipitation = 4 10-25 <br /> n-Site Wells) es f o umber 8 Type Irr om I ub <br /> S Score S core Score <br /> istance to Well(s) from Tank it; ft; it C 0 pts C pts C pts <br /> 0 if 0 1f 0 if <br /> R onditI on R and i t i on R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum 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 f' Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26.40\2 <br /> nn-Made conduits which increase vertical migration - <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown >resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. p At leas[ ore than <br /> xxxxx None ( one one <br /> COLUMN TOTALS>>>TOTAL POINTS + 27 + �D / <br /> 'ample Result: III <br /> (D T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 [s or less <br /> �`� C -a P-�ry 8 T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> ample Result: <br /> ASOLtNE 1000 100 10 <br /> �m AXIMUM ALLOWABLE TPH LEVELS (PPM) EE <br /> TPH IESEL 10,000 1000 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 <=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 TPM concentration of 10 ppm (gasoline) or 100 pprn (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o 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 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED ATE CLOSURE LETTER MAILED I //; / <br /> AME OF C— /7�1 <br /> VALUATOR i/ �// f <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />