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SAN JOAQUIN C�Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAi)IVISION <br /> ), GST WORKSHEET FOR SITE CLOSURE EVALUATION ATE (�_ - <br /> AME OF FACILITY ) _ EEPS CODE /y u.3 <br /> GORE 55 /5 � 5 _ 7// <br /> IANK SIZE '&,JV UEL <br /> II. GENERAL SITE HISTORY .. <br /> Is permit current7 es u o ermit # p - /SJ.� ac [y Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility G> ge of Tanks(if available) ype of Tank Leel Fbrgl ngl Dual <br /> ill. TANK HISTORY <br /> Jas Tank tested? an o ailed precision test 7 es o If yes, give date(s) <br /> as a repair made to the tank system? as No f yes, what was repaired? <br /> 'as repair done under inspection7 as o ere soil samples analyzed? as o TXE PH-G PH-D b/EDD <br /> Type of failure/discharge atastrophic long-term leakage verfill nknown I lother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ail Samples Received es o epth to Ground Water age Annual Precipitation 4 0- <br /> -Site Well(s) as o umber i( Type Irr an ub <br /> S Score S Score S Score <br /> istance to Well(s) 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 ondition <br /> Site Feature ' Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sampte (feet) >100 1-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 25.40\2 <br /> an-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 Sail, nearby wells. At least lore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS ' + <br /> Simple Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pis or more 41 - 48 pts 40 pts or less <br /> D 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 /> arrple Result: PASOLINE 1000 11 <br /> 100 10 <br /> AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH—(j IESEL 10,000 1000 100 <br /> OOTNOTES: ---if documented soft and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currentLy on UCT 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 TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> J!. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX $ E or TPH Concentrations > Allow abl -Levels Yes o <br /> 2. Recommend Site Closure as 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 I EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> )ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> LANE Of <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />