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SAN JOAOUIN 4 tOPU8LIC HEALTH SERVICES/ENVIRONMENTAL NEAP ISION <br /> 1. UaT, WRKSHEET FOR SITE CLOSURE EVALUATION ATE 3_IS <br /> AME OF FACILITY O Q CCCNIEV <br /> CL-0 l7 a _, EPS CCOElovqq <br /> nORESS C _� ^� ANY (D # <br /> l-- 7 <br /> TANK S12E I IFUEL TYPE - t <br /> 11. GENERAL SITE HISTORY <br /> i <br /> Is permit current? es ohermit # - acility Status Code cc.Soil/GW Conc as o ) <br /> under of Tanks at facility Be of Tanks(if available) ype of Tank Leel I brgl I ngI Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested? es o ailed precision test 7 es o if yes, give date(s) <br /> / <br /> as a repair made to the tank system? Ires10 No f yes, what was repaired? U rjow LS 1 - TnW°a <br /> as repair done under Tnepection7 If <br /> as o ere soft salpies analyzed7 es o I OTXE I PH-G I PH-D I b/ED8 <br /> ype of failure/discharge catas rophic I ILong-term leakage verfill nknown then. <br /> IV. REMOVAL HISTORY (ATTACH INSP TION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received as o epth to Ground Water y�/. of Yeaverage Annual Precipitation = 4 0-25 <br /> -Site Wells) es o urber 8 Type 0. Irr an ub <br /> S to S core S 3core f <br /> istance to Welts) frac Tank LLVl t; ft; it C 0 pts C 9 pts C 5 pts <br /> 0 f 0 if 0 if <br /> R cndition R condition R ordition <br /> 1. Site Feature - Leaching Potential Analysis E is met E is met E is mac <br /> inimua Depth to groundwater from the Soil Saaple tfeet)L,IO-gyp;�jO� >100 1-100 5 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) More Unknown resent% 4 <br /> verage Annual Precipitation (inches) uxxxx <10 9 10-25 XXXXXX 26-40\2 <br /> on-Made conduits which increase vertical migration <br /> 1 leachate (i.e., septic systems, water wells, ponds) - None Unknown 5 resent <br /> ique site features: Recharge area, coarse soil, nearby wells. At Least iore than <br /> one <br /> xxxx more �J one <br /> COLUMN TOTALS»>TOTAL POINTS + + ! D <br /> ample R 5ult-' (8 T X OR E) RANGE OF TOTAL POINTS 9 pts or acre 41 - 48 pts 40 pts or less <br /> B T % E B T E <br /> '1 QPM HA%IHLH ALLOWABLE B-T-x-E LEVELS (PPM) 1 50 50 50 .3 .3 1. i. NA\3 <br /> angle Result:�[�-(\,1 <br /> SOLINE 1000 100 10 i <br /> Q O r AXIMUM ALLOWABLE TPN LEVELS (PPM) 100 <br /> V TPH IESEL 10,000 1000 � <br /> DOTHOTES: ...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. p� (gasoline) or 100 (diesel). <br /> k <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 FP^ ( f <br /> VI. STAFF RECCMMENDATION/CONCLUSION <br /> 1. Are BTX S, E or TPH Concentrations > ALLo able levels Yes o <br /> 2. Recommend Si ce Closure es o If Yes, Refer to Site Mitigation for Evacuation <br /> .11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLMRE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED �/ ,� / ATE CLOSURE LETTER MAILED <br /> LAME OF k <br /> :VALUATOR k <br /> EH 23 80 (UGTUKSHT)\5/90. <br /> j <br />