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SAN WOACUIN COON ELIC HEALTH SERVICES/E4VIRCNMEHTAL HEALTHI 1StCN <br /> u' ,aRXSHEET FOR SITE CLOSURE EVALUATION ATE ? <br /> AME OF FACILITY //� EEPS LCOE - <br /> nORESS QQ �v C — ANY 10 4 <br /> IANX SIZE 40V UEL TYPE <br /> I. GENERAL SITE HISTORY <br /> Is permit current? es o arm 19. <br /> - acitity Status Code ae.Sail/GW Cant as o <br /> wnber of Tanks at facility of Ianks(if available) ICLtype <br /> of Tank teal brgl rgl Dual <br /> If. TANX HISTORY <br /> ms Tank tested? es o ailed precision test 7 es o If yes, give dates) lam) <br /> as a repair made [o t e tan#System? Ho f yes, chat vas repaired? <br /> 'as repair done under inspeca ere soil samples analyzed? es o TXE PH-G PH-If ype of failure/discharge longterm leakage vertill known cher: <br /> V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received as o epth to Grou)d 'Water t✓i of/Tear g 3 3 ver age Annual Precipitation Nz 4 0-25 <br /> -Site Wells) es o umber b Type Irr I ub <br /> S Scare S Scare S Score <br /> istance to WeLI(s) frac Tank ft; f[; it <br /> C 0 pts C pts C pts <br /> O if 0 if 0 if <br /> R condition R Condition R ondicion <br /> Site Feature - Leaching Potential Analysis E is mac E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25.50\1 <br /> ractures in subsurface (applies to foothills or motntain areas) more !.t Unknown resent <br /> vcrage Annual Precipitation (inches) xxxx <10 9 10-25 KXXXXXX 26.40\2 <br /> .n-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> iq;e site features: Recharge area, coarse soil, nearby wells. At least are than <br /> xzxx Noe �j <br /> we one <br /> COLUMN TOTALS>>>TOTAL POINTS ' <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pcs 40 pts or less <br /> 8. •ovj5ppl g=,Cot ppM <br /> .+� rWt) PP-1 B T X E B T X E <br /> <O4Vp'f MAXiMLH ALLCWABLE B•T•X•E LEVELS (PPM) 1 50 50 SO .3 .3 1. 1. NA\3 <br /> ample Result: ASOLINE 1000 100 10 <br /> MUM ALLOWABLE TPH LEVELS (PPM) 100 <br /> !g2 RP01 TPN--0 AXIIESEL 10,000; 1000 <br /> FOOTNOTES. •"If documented soil and/or ground water contamination is press a, do not complete the Leaching potential <br /> sratysis. (i.e., site is currently on UGT Contamim Clan List for soft 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 BTXEE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> STAFF RECCHHENOATICN/CCNCLUSION Q <br /> 1. Are BT% 3. E or TPH Concentrations > Allowable Levels Yes o {�� jlGy�.�— <br /> 2. Recommerd Site Closure [ as o If Yes, Refer to Site Mitigation for Evaluation <br /> :(. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECCHMENOATICH FOR CLOSURE IT=, <br /> ES 0 EFERRED TO SITE 41TIGAT ICN FOR EVALUATICN ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED / <br /> LAME Of <br /> :VALUATOR <br /> EN 23 80 LUGTWXSHT)\5/90 . . <br />