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�► i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL NILoill DIVISION <br /> UGST YOKSNEET FOR SITE CLOSURE EVALUATION ATE <br /> OF FACILITY �— EPS CODE <br /> $S 3100 O0 1 • C� ANK ID S <br /> AMK SIZE 10 Q 0 L TYPE <br /> II. GENERAL SITE HISTORY <br /> w+ <br /> s permit current? kes I oresit it :: seility Status Code oc.Soft/GW Cont as <br /> r of Tanks at facility 3 ge of Tanks(if available) yF of Tank teel I—Fgt_l U I Dust <br /> III. TANK HISTORY <br /> Jos Tank tested? es silsd precision test ? to o If yes, give dmte(s) <br /> a repair mads to the tank system? es No f yes, what was repaired? <br /> • s repair done under inspection? es io re soil samples analyzed? as TXE PN-G -D /EDB <br /> ype of failure/discharge I tastrophic tow-term leakage rfItl I jinknow I they: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> it Samples Received K epth to Ground Yater GIDS of/Year ; �Z(=r verage Annual Precipitation 4 0-25 <br /> -Site Yelt(s) IYes r i T, � ype Irr om <br /> S core S core S ore <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 0 pts C pts <br /> 0 if 0 if 0 f <br /> R audition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soft Sample (feet) >100 1-100 25-501 <br /> rectures in subsurface (applies to foothills or mountain areas) L) Nene Unknown resent <br /> verage Annual Precipitation (inches) Kxxxxx <10 9 10-25 xxxxxxx 26-40L <br /> -Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) Nana Unknown 5 resent <br /> ique site features: Recharge was, coarse soil, nearby wells. Q At least 4ore than <br /> KXXXXX Nana / one c one <br /> COLUMN TOTALS>»TOTAL POINTS 7 t J 33 <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS S>pts or more 41 - 48 pts 40 pts or less <br /> b 6� epb X 33p/b B Tx t? e T JXJE <br /> MAXIMUM A4LOWABLE B-T-X-E LEVELS (PPM) 1 5050 50 .3 3 11. NAM <br /> ;ampte Result: INE 1000 100 10 <br /> IMM ALLOWABLE TPH LEVELS (PPM) <br /> 21201 TPH IESEL 10,000 1000 100 <br /> OOTNOTES: '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 /> �] If depth is > 5 ft. and < 25 ft.. score 0 points. If depth �c-5 ft., do not use table. <br /> If precipitation is > 40 inches, score 0 points. <br /> Levels for BTX&E are not applicable at a TPM concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX i E or TPN Concentrations > Allowable levels Yes—To <br /> 2. Reccemend Site Closure " 0 1 if Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO M COMPUTED BY A SUPERVISOR/SENIOR <br /> PWITH STAFF RE TION FOR CLOSURE ES EFERRED TO SITE MITIGATION FOR EVALUATION ES <br /> EFERRED / / ATE CLOSURE LETTER MAILEDF <br /> TOR <br /> EN 23 80 (UGTMMNT)\55/90 <br />