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SAN JOACU18 COJ4ELIC HEALTH SZ7VICES/ENVIRONMENTAL HEALTH (SIGN <br /> UG&RKSHEET FOR SITE CLOSURE EVALUATICN • ATE <br /> nME OF FACILITY 'EEPS CODE a y,•� <br /> AnORESSI //2cicia��� ANK TO x 39 - a y�G - C <br /> LANK SIZE d-r7 p UEL TYPET _5 <br /> . GENERAL SITE HISTORY <br /> Is permit curren[7 es o ermit Al - acility Status Code j oc.soi I, Cant es o <br /> unber of Tanks at facility Be of Tanks(if available) ype of Tank tee) brgl ngl I Dual <br /> :. TANK HISTORY <br /> ms Tank tested7 es o ailed precision test 7 es o If yes, give date(s) <br /> a repair made to the tank system? 1Yes No f yes, what was repaired) <br /> :as repair done under inspection? es o ere soil samples analyzed7 es o 1 16 TXE I PH-(;x <br /> PH-0 I b/E08 <br /> ype of failure/discharge atas[rophic long-term leakage verfilt nknown Cher: � <br /> . REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ioit Samples Received es V4. <br /> epth to Gravel Vater of/Tear �'a verage Arnual Precipitation = 6 0-25 <br /> On-Site wells) es a umber 3 Type Irr W ub vv <br /> � S coreS core S core <br /> `istance to WeLL(s) from Tank ft; ft, ft C 0 pts C pts C pts <br /> 0 if 0 if 0 f <br /> R ondition R ondition R ondition <br /> ?. Site Feature Leaching Potential Analysis E is met E is met E s met <br /> iinimum Depth to groundwater from the Soil Sa- <br /> p eet) >100 1.100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain er Hone Unknown resent <br /> +vcrage Annual Precipitation (inches) 9 10-25 xxxxxxx 26.60\2 <br /> �,in-Made cortiuits wftich increase vertical migration <br /> I of teachate (i.e., septic systems, water wells, ponds) None nknown resent <br /> Jnip:e site features: Recharge area, coarse soil, nearby wells. least are than <br /> xxxx None a one <br /> COLUMN TOTALS>>>1OTAL P0I4TS + + <br /> Camole Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 61 - 68 pts GO pts or less <br /> T XE 8 T X E <br />' ��h =�•b MAXIMUM ALLOWABLE B-T•X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: /�7 ASOLINE 1000 100 10 <br /> AXIMUH ALLOWABLE TPH LEVELS (PPH) <br /> UU Y TPH��j IESEL 10,000 1000 100 <br /> r COT40TES: ...If documented soil and/or ground water contamination is present, do not ccmplete the teaching potential <br /> analysis. (i.e., site is currently on LOT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 f[. and < 25 ft., score 0 points. If depth 4=5 ft., do not use table. <br /> \2 If precipitation is > 60 inches, score 0 points. <br /> \3 Levels for BTXSE are rat applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> I. STAFF RECCFMENOATION/CCNCLUSION �, , p S„__ „p, n•,_ " �,.,� � e <br /> 1. Are BTX S. E or TPH Concentrations > Atlowable Levels Yes o �•K•� ",t /`�'7"" -`-�'�b/ <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation) <br /> REVIEW EVALUATICN - TO BE COMPLETED BY A SL'PEBVISCR/SENICR <br /> ".ONCUR WITH STAFF RECCHME40ATICN FOR CLOSURE SES 0 EFERRED TO SITE MITIGATION FOR EVALUATICN (�'ES 0 <br /> )Lc REFERRED / / ATE CLOSURE LETTER MAILED ` <br /> � <br /> uNE Of <br /> ULUATOR <br /> '.'A 23 80 (UGTWKSHT)\5/90 <br />