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SAN JOACUIN CCUNBLIC HEALTH ScR'VICSS/ENVIRCNNENTAL HEALTH [SIGN <br /> I. UG_ CIRXSHEET FOR SITE CLOSURE EVALUA71ON <br /> AME OF FACILITY 6 EPS COOE <br /> nORESS q0 If 4j? L'-1,-yl Z TANK 10 Al � - �Z- 3 0� <br /> [ANY, SIZE rQ UEL TYPE <br /> 11. GENERAL SITd HISTORY �* <br /> is permit current? 11 <br /> es oV11Permit 9 - acitity Status Code oc.5 it/Gv Cant es o <br /> unber of Tanks at facility ge of Tanks(if available) 'ype of Tank teeL IVIFbrgL I Isogl OuaL <br /> III. TANK HISTCRY <br /> tis Tank teste=es , ailed precision test 7 es a If yes, give date s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> -is repair done under inspection7 Yes No IV ere so it samples analyzed? es o TXE ?H-G NPH-0 Ta/E06 <br /> Type of failure/discharge atastrophic lmg term leakage verfiIt known ther: <br /> IV. REMOVAL HISTCRY (ATTACH INSPECTION REPORT FCR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ail Samples Received es o epth to Grouxj eater of ear ; verage Annual Precipitation = 4 0-25 <br /> -Site SleLL(s) IYes a umber 3 Type Irr cm ti ub <br /> S Score S Score S Score <br /> )(stance to Well(s) from Tank Oft; ft, ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R ondition R ordition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimun Depth to groundwater from the Sail Sampte <feet) tj( -_is��7 >100 i-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) l ( ) ?lone Unknown resent <br /> vcrage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> an-`face conduits which increase vertical migration <br /> i leachate (i.e., septic systems, water wells, pends) None Unknown resent <br /> 'ni ,cue site features: Recharge area, coarse sail, nearby wells. At least are than <br /> xxxx More one I one <br /> COLUMN TOTALS—TOTAL POINTS + + r / <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 ,pts or more 41 - 48 pts 40 fits or less <br /> OA"IpW% S 1 T X £ 8 7 X E <br /> HAXIHLM ALLOWABLE 8-T-X-E LEVELS (PPN) 1 50 50 50 .3 .3 1. 1. 4A\3 <br /> Sample Result: �AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> ASOCINE 1000 100 10 <br /> A)-DTPN IESEL <br /> 1 10,000 1000 100 <br /> CONNOTES: "'If documented sail and/or ground water contamination is present, do not ccmplete the leaching potential <br /> anatysis. (i.e., site is currently an UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <w5 ft., do not use table. <br /> \2 if precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 pM (gasoline) or 100 ppm (diesel). <br /> V1. STAFF R€C0WENOATICN/CCAICLUS:CN <br /> 1. Are BTX 3 E or TAH Concentrations > Allowable LeveLs Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for EvaLuation <br /> VII. RETIES! :VALUATICN - TO BE CCHPLETED BY A SUP€RVISOR/SENICR <br /> CONCUR WITH STAFF BECCHHE40ATICN FOR CLOSURE IES 0 EFERRED TO SITE HITICATICN FOR EVALUATICH ES O <br /> AIE .REF=RREO / / ATE CLOSURE LETTER !TAI=ED � -/ / <br /> F <br /> 6CFnLUaicR <br /> EH 23 80 (UGTuxSHT)\5/90 <br />