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SAN JOAOUIN CC4 \.1' IC HEALTH SERVICES/ENVIRONMENTAL NjA �f 'N ATE/ <br /> WORKSHEET FOR SITE CLOSURE EVALUATION <br /> I. <br /> SWEEPS CODE 1 ,S 3 1 <br /> AME OF FACILITY �j0/L <br /> / NK IO X - <br /> �OORESS a ?tw <br /> / <br /> IANK SIZE 100' 0� <br /> GENERAL SITE HISTORY " <br /> ' <br /> acitity Status Code <br /> Is permit current? es o ermit # oc.Soil/GW Cant es o <br /> ge of Tanks(if available) ype of Tank Leel fbrgt ngl Oual <br /> unber of Tanks at facility <br /> 0 <br /> :t 1. TANK HISTORY to <br /> as Tank tested7 es o ailed precisi m test 7 es <br /> o jXjIf yes, give <br /> ',las a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es go ere soil samples anatyzed7 es o TXE PH•G PH-0 bfE08 <br /> ype of failure/discharge atastrophic long-term leakage verfitt nknoun ther: <br /> v. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samptes Received es X o epth to Ground Nater 1D of/Year <br /> Fveragennual Precipitation = 4 0-25 <br /> -Site Wells) es o umber S Type Irr om ub core <br /> S core core S is <br /> ft; ft C 0 pts Pts C fP <br /> Distance to Well(s) from Tank / _ft: 0 if 0 if 0 <br /> R rondition R condition R ondition <br /> E is met E is met s met <br /> Site Feature - Leaching Po tial Analysis £ <br /> inimum Depth to groundwater from the l Sample tfeet) 25-50\1 <br /> 1-100 <br /> >100 <br /> Fractures in subsurface (applies to foothill r mountain areas) <br /> None Unknown resent <br /> xxxxx <10 9 10-25 xxxxxx 26-40\2 <br /> vcrage Annual Precipitation (inches) <br /> an-Made conduits whichincrease vertical migration on `— Unknoun 2resent <br /> f teachate (i.e., septic systems, water welts, ponds) <br /> Least ore than <br /> ique site features: Recharge area, coarse soil, nearby welts. one one <br /> x <br /> COLUMN TOTALS»>TOTAL POINTS <br /> a le es lt: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 4 48 p p s or less <br /> 'S;, <br /> B T X E B T X <br /> S MAXIMLH ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> _7141- 1 �tESEL <br /> LINE 1000 100 10 <br /> Sample Result pAxles LLOWABLE TPH LEVELS CPPV) <br /> 10,000 1000 100 <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 UGT 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 aTX&E are not applicable at a TPH concentration of 10 ppm <br /> (gasoline) or 100 ppm Cdieset). <br /> A. STAFF RECCF44ENDATION/CCNCLUSION <br /> 1. Are BTX b E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation w <br /> '11. REVIEW EVALUATION - TO SE CCHPLETED SY A SUPERVISOR/SENIOR <br /> ONLUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED Y <br /> SAME OF _j <br /> :VALUATOR <br /> EH 23 30 (UGTWKSHT)\5/90 <br />