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SAN JOACUIN CCUNELIC HEALTH Sc-RVICES/E.4VIRCNMENTAL 4EAL1H SICK <br /> 1. UG ORXSHEET FOR SITE CLOSURE EVALUATICN ATE — 6, <br /> 4A ME OF FACILITY[� /C',�q' , / EEPS CCOE JY ? <br /> 00 RE SS TQ 7 D 4� J -j' L1/.�._�-W, AHK 10 2tZ- 3-J-0_ <br /> btNK SIZE �qC> UEL C <br /> 11. GENERAL SITE HISTORY <br /> is permit current? es o ermit N - acility Status Code oc.Soil/GW Cant es o <br /> user of Tanks at facility .� Be of Tanks(if available) ype of Tank reel Fbr gl ngl Oual <br /> III. TANK 4ISTCRY <br /> ns Tank tested? es c ailed precision test ? es o V If yes, give date(s) <br /> as a repair made to the tank system? es 40 f yes, what was repaired? <br /> 'as repair done ruder inspection? es o ere soil samples analyzed? es o TXE PH-G PH-0 b/EDB <br /> ype of failure/discharge atastrophic Long-term leakage verfill nknown cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FCR LEAC41MG POTENTIAL ANALYSIS) <br /> oil Samples ReceivedI es o epth to Ground Water of/Year verage Annual Precipitation = L 0-25 <br /> Site Wells) es o umber S Type I Irr CMrub <br /> S core S Scare S Score <br /> istance to Well(s) from Tank I a ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ordition <br /> Site Feature - Leaching Potential Analysis E is met E is met E5 met <br /> inimum Depth to groundwater from the Soil Sample tfee t) >100 1-100 25.50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) ! V, None Unknown resent <br /> vcrage Annual Precipitation (inches) xxxx <10 9 10-25 xxxxxxx 26.40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) More Unknown resent <br /> ni¢;e site features: Recharge area, coarse soil, nearby wells. At least �1ore than <br /> xxxx None one I one <br /> COLUMN TOTALS»>TOTAL POINTS +� * ' <br /> ample Result: IS T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> S-5� Pwr Zr-C.. 8 T % E 8 T X E <br /> S� �o�� T e <br /> MAXIHLH ALLCWABL_ B-T•X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> ample Result: ASOLINE 1000 100 10 <br /> A)(IHJM ALLOWABLE TPH LEVELS (PPM) <br /> N TPH IESEL 1 10,000 1000 100 <br /> COT.40TES: --if documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or groud 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 3TX8E are rot applicable at a TPH concentration of <br /> tC 10 ppm (gasoline) 'o"r,.,10�0,,PPM (diieselp).. <br /> Vt. STAFF RECCF4IENOATICN/CCtICLUSICN Jta 1 hf-Saotp-w V-44cZ , <br /> 1. Are 3TX S. E or TPH Concentrations > Allowable Levels Yes o I <br /> 2. Recomaerd Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> Vtl. REVIEW EVALUATION - TO BE CCMPLETEO BY A SUPERVISOR/SENIOR <br /> .CHCR WITH STAFF RECCNMENOAT ION FOR CLOSURE 4ESI 0 I EFERRED TO SITE MITIGATICM FOR EVALUATICN 4E5 0 <br /> nTE REFERRED / / ATE CLOSURE LETTER MAILED { / <br /> tavE OF <br /> :VALUATOR <br /> EH 23 80 (UGTWXSHT)\5/90 <br />