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SAN JOACUIN CCU W8LIC HEALTH SERVICES/ENVIRONMENTAL HEALTH�ISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> EEPS CODE <br /> nME OF FACILITY <br /> ANK 10 d <br /> 00 RE SS <br /> IANK SIZE �p�) UEL TYPE I�A _ > <br /> II. GENERAL SITE HISTORY <br /> Ega!-5 <br /> ermit p ' acili[y Sta[us Code , oc.SoillGv Con[ es Be of Tanks(if available) ype of Tank tee/ VfbrgI ngl Oual <br /> 111. TANK HISTORY <br /> ms Tank tested? es a ailed precision test t es o If yes, give dates) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done underinspection? es o ere soil samples analyzed? e a TXE PH•G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verfill nknown I 6cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ail Samples Received s o epth to Ground Water 'of ef/ ear L53(, ; ve rage Arnual Preci pi Cation <br /> -Site WeLt(s) es o umber 3 Type Irr am ub <br /> S core 5 Score S 3core <br /> istance to Wells) from Tank a�f t; ft; ft C 0 pts C pts o .fpcs <br /> 0 if 0 if <br /> R ondition R condition R ordition <br /> 1. Site Feature - Leaching Potential Analysis E is met E is mac E is met <br /> inimum Depth to groundwater from the Soil Sample (feet)��--15_jJ >100 1-700 25-50%1 <br /> Fractures in subsurface (applies to foothills or mountain areas) 1 11 <br /> More Unknown <br /> 10.25 xxzxxx resent <br /> Average Annual Precipitation (inches) xxxxx <10 9 26.40\2 <br /> an-Made conduits which increase vertical migration Unknown resent <br /> F leachate (i.e., septic systems, water wells, ponds) Hone <br /> /j At least ore than <br /> ni yve site features: Recharge area, coarse soil, nearby cells. '—I1 one one <br /> xx <br /> xx None �/(y xGy <br /> COLUMN TOTALS>>>TOTAL POINTS 0 t U 1 I `-' <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> XgQPtf2 :"�3T'Prn B T % E B T X E <br /> MAXIMLIM ALLOWABLE B-T•X-E LEVELS (PPH) 1 50 50 50 .3 .3 1. 1. F14A\3ample Result: ASOLINE 1000 100 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) 100 <br /> n.TPN IESEL 10,000 1000 <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 TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECCNWENOAT I ON/CONCLUSION pq <br /> i. Are BTX E or TPH Concentrations > Alto ble Levels Yes o 5 n IC f725 �""' � <br /> Ccrn 64iivc�a°v ' G{hct� l(Z <br /> 2. Recommend Site T a'4V <br /> Closure es o \ If Yes, Refer to Site Hitigation for Evaluation /u^h L <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR U <br /> -ONCJR WITH STAFF RECCMMENDATION FOR CLOSURE ES 0 EFERRFD TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED V / 2 / J ATE CLOSURE LETTER MAILED <br /> nHE OF <br /> nLUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />