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SAN JOAOUIN §TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAR DIVISION o <br /> ), LOST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY WEEPS CODE I <br /> ODRESS ANK ID # <br /> TANK SIZE Q� UEL TYPE <br /> II. GENERAL SITE HISTORY ** <br /> Is permit current? es o ermit # acility Status Code IDoc.Soil/GW Cont es Jo <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank Leel Fbrgl nSl Dual <br /> III. TANK HISTORY <br /> as Tank tested? Ires o IF ailed precision test ? If <br /> es o If yes, give date(s) <br /> as a repair made to the tank system? Yes No f yes, what was repaired? <br /> ns repair done under inspection? es 40 ere soil samples analyzed? es Jo TXE PH-G PH-D b/EDD <br /> ype of failure/discharge atastrophic long-term leakage I verfill nknown Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> soil Samples Received es o epth to Ground Nater of/Year -71Y& ; verage Annual Precipitation = 4 10-25 <br /> -Site Well(s) es o umber 8 Type Irr om ub <br /> S core S core S core <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C pts C pts <br /> 0 if 0 if 0 'f <br /> R ondition R ondition R onditi on <br /> V. Site Feature - Leaching Potential Analysis E is met E is met Es met <br /> inimum Depth to groundwater from the Soil Sample (feet) ] >100 1.100 S 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) Q None 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 5 resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least Jc ore than <br /> xxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS 1 1S 3V <br /> ample Result: A(D T % AAOR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> 6 T X ND /u�� D T X E B T X E <br /> // MAXIMUM ALLOWABLE D-T•X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> 'ample Result: ASOLINE 1000 100 10 <br /> r-) , <br /> H AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> Y" TPIE SEL 10,000 1000 100 <br /> OOTNOTES: ***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 TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1, Are DTX 8 E or TPN Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure as o If Yes, Refer to Site Mitigation for Evaluation 8 <br /> VII, REVIEW EVALUATION • TO BE COMPLETED BY A SUPERVISOR/SENIOR n^ a 10S C—, <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE 'ES '0 EFERRED TO SITE MITIGATION FOR EVALUATIO ES JO <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AMEOF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />