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SAN JOAQUIN COUNTY P 'C HEALTH SERVICES/ENVIRONMENTAL HEALTH 01' ON <br /> UGST Wl SNEET FOR SITE CLOSURE EVALUATION ATE <br /> IME OF FACILITY �^ EEPS CODE <br />)DRESS •7L0 D ANK TO X �b <br /> 4NK SIZE UEL TYPE <br /> GENERAL SITE HISTORY <br /> s permit current7 Ifes o ermit M IFacility Status Code oe.Soil/GW Cone os 10 <br /> umber of Tanks at facility ge of Tanks(if available) ypa of Tank IS <br /> teal I IF <br /> brgl ngl I Dual <br />. TANK HISTORY <br /> as Tank tested? es IFailed precision test 7 as o If yea, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired! <br /> as repair done under inspection) es o dere soil samoles analyzed? es )o TxE PH-G (7 PH-O b/E00 <br /> Yoe of failure/discharge acastrophid long-term leakage verfill nown Cher: <br /> REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT TATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received as o epth to Ground water of/Tear verage Annual Precipitation x 4 10-25 <br /> n•Site well(s) es o umber S Type Irr om b <br /> S core S core 5 core <br /> Distance to Wells) from Tank ft; _ft; ft C 0 pts C pts C pts <br /> •0 'f 0 �if 0 -f <br /> R ondition R pnd ition R ondi tion <br /> Site Feature - Leeching Potential Analysis a �is mac E Is met E is met <br /> linimun Oepth to groundwater from the Soil Sample (feet) I >100 1.100 25.50\1 <br />--actures in subsurface (applies to foothills or mountain areas) Nane Unknown resent <br />�crage Annual Precipitation (inches) xxxx <10 19 10-25 xxxxxx 26.40\2 <br />'an-Made corcuits which increase vertical nigration <br /> 1( leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br />:nioue site features: Recharge area, coarse soil, nearby wells. At least i+ore than <br /> xxxx Nara one I one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> i <br />:ample Result: (0 T X OR E) RANGE OF TOTAL POINTS 9 pts or more / 41 48 pts 40 pts or• less <br /> ^u T X "c 3 T X E <br /> / <br /> MAXIMUM ALLOWABLE D-t•X•E LEVELS (PPM) 1 50 50 50 I .3 .3 11, I 0\3 <br /> iample Result: SOLINE 1000 100 10 <br /> �'�`� IfRNt ALLOWABLE TPX LEVELS (PPM) <br /> TPN bIESEL 10,000 1000 100 <br />'COTNOT-c S: —'If docunenced soil and/or ground water concami nation is present, do not conolete the leaching potential <br /> anaiysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., scare 0 points: If depth 4_5 ft., do not use :able. <br /> \2 If precipitation is > 40 inches, score D points. <br /> \3 Levels for 3TX&E are not applicable at a TPN concentration of 10 ppn (gasoline) or 100 dpm (diesel). <br /> STAFF RECOMFIENDATION/CONCLUSICN <br /> 1. Are 3TX 3 E or TPN Concentrations > Allowable Levels Yas o l' <br /> 2. Recommend Site Closure es )/ o If Yes, Refer to Site Mitigation for Evaluation <br /> I. REVIEW EVALUATION - TO 3E COMPLETED 3Y A "SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATICN FOR EVALUATION ES `10 <br /> ATE REFERRED i �.ArE CLOSURE LETTER MAILED / <br /> i <br /> h.:wF OF <br /> ALUAIOR <br /> EM 23 iL <br />