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SAN JOAOUIN <br /> I PUBLIC HEALTH SERVICES/ENVIRONIENTAL NEA 41VISION <br /> COST tARKSHEET FOR SITE CLOSURE EVALUATION V .�OF FACILITY I 1-i, AmolAA ZA/W Ad fp CDRD Ia3 /�lo Fr <br /> R£SS I AUK IO # <br /> ANK SIZE a060 <br /> TYPE <br /> It. GENERAL SITE HISTORY <br /> S permit current? Ires o -t IFacility Status Code oc.Sof l/GW Cont as o <br /> umber of Tanks at facility F90 of Tank(if available) IType of Tank Leet l i Not <br /> III. TANK HISTORY !� <br /> as Tank tested? kOs o ailed precision test tes o f yes, give date(s) <br /> s a repair made to the tank system? as !!- f yes, what was mired? <br /> S repair done under inspection? es o soil samples anelyzed7 es <br /> PN-G PH-D /EDB <br /> ype of failure/discharge tastraphie orq-tone leakage ill <br /> then. <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT Felt SITE DET I DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ISO it Samples Received kes o epth to Ground Water. ef/Yesr g� versge Amust Precipitation = 4 0-25 <br /> Fes pe <br /> -Site WeIL(s) o i Tyrr Om <br /> S core S core S ore <br /> istanca to Wells) from Tank ft; ft; ft C 0 pts C pts C s <br /> 0 f 0 'f 0 fPt <br /> R onditicn R andition R ondition <br /> Site Feature - Leaching Potential Analysis E s met E is met E s met <br /> Minimum Depth to groundwater from the Soil Sampte (feet)&3 j R-R3 1,1001 1-100 25-50L <br /> rac:ures in subsurface (applies to foothills or mountain aress) None Unknown resent <br /> verage Annual Precipitation (inches) am= <10 9 10-25 26-40_? <br /> Ian-Made conduits which increase vertical migration <br /> � f Leachate (i.e., septic systems, water wells, ponds) f 9 None Unknown resent <br /> unique site features: Recharge ares, coarse soil, or wells. I At Least re than <br /> f (Muneipai-2000 ft; daaaestica1,5OO ft; irr/agri=it turn L=presentl Nana one ane <br /> COLUMN TOTAM-3-TOTAL POINTS ® f I b <br /> Sample Ru t: (B T X OR E RANGE TOTAL POINTS 9 pts or sore 41 - 48 pts pts or <br /> esless <br /> r <br /> 6 <br /> 05 f" 1 AX11"4 ALLONABt.E B-T-X-E LEYELS (PPM) g 50 50 50 .3 <br /> [3T <br /> 1. E NA <br /> ampteeyResult: IME 1000 100 10 <br /> IV D TPH C1, 4AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> IESEL 10,000 1000 100 <br /> THOTES: ***If documented soil and/or ground water contamination is present, do not complete the tesching potential <br /> anslysis. (i.e., site is currently on UGT Contamination List for snit or ground water.) <br /> 11 If depth is 1, 5 ft. and < 25 ft., seore 0 points. If depth -5 ft., do not use table. <br /> \,a If precipitation is 1, 40 inches, score 0 points. <br /> L Levels for BTXiE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 <br /> ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION rn?13 L / L'AJ�.J i1 j 0 <br /> 1. Are BTX 6 E or TPN Concentrations 1, Allowable Levels as o <br /> lal�sf�tc� h ^K� <br /> 2. Recamnend Site Closure Iv,es o If Yes, Refer to Site Mitigation for Evaluation .3.3 �`� <br /> '!II. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> WITH STAFF RECOMMENDATION FOR CLOSURE ES EFERRED TO SITE MITIGATION FOR EVALUATION rES <br /> AT-e REFERRED i / ! ATE CLOSURE LETTER MAILED <br /> AFE OF Vv <br /> VALUATOR <br /> .H 23 80 (UGTWKSHT)\5/94 <br />