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SAN JOAQUIN C&%OLIC HEALTH SERMES/ENVIRCNMENTAL RE,tl� tow <br /> f. UCST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> Ar.E OF FACILITY ( Q� EPS CODE Z'e <br /> FREss Z-/pa lel �GGlO'T AN% :o <br /> ANX SIZE Wy, �;,ra L TYPE <br /> It. GENERAL SITE HISTORY <br /> s permit current? to 1g. erect / scittty status Code oe.Soil/GW Conc is <br /> of Tanks at facility qe of Tonks(If available) ype of Tank test !u'gl l Dust <br /> III. TANK HISTORY <br /> s Tank tested? is o ailed precision test 1 as Ito f yes. give dates) <br /> ms a repair lade to the tank system? tea No I f yes, what was repsIredT <br /> repair done under inspection7 es go ere soil samples onstyse n ss o TXE PM-G PN-0 E08 <br /> ype of facture/discharge1. atostrophic ong-term leakage erfIIt ther: <br /> IV. REMOVAL NISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oit Samptes Receivedac o epth to Ground Water ef/Year ;{ ; y. "_': -erage Amort Precipitationiondt <br /> ■ 4 0-Z5 <br /> -Site Wett(s) es o r i Type rr ce <br /> S core S are S care <br /> Istance to Wett(s) from Tante ft; ft; ft C 0 pts C pts C pts <br /> O f 0 if 0 f <br /> R ondItian R ondition R tion <br /> Site Feature - Leaching Potential Anatysis E s set E is met E s met <br /> inimm Depth to groundwater from the Soil Sasp(s (feet) D� >t00 1.100 25.50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) Nana Unkno.n 3resmnt <br /> -crags Annual Precipitation (inches) CULXXX 410 9 10-25 Kxxxxxx 26-40\2 <br /> -Made conduits which increase vertical migration <br /> f teschate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> ique site, features: Recharge area, coarse soft, nearby wells. At least We than <br /> KXXXXX None ens one <br /> • COLUMN TOTALS>»TOTAL POINTS <br /> ;ampis Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 40 pts 40 pts or less <br /> �`'tf�"► B T X E t T X E <br /> MAXIMIM ALLOWABLE B-T-X-E LEVELS (PPM) 1 SOSO SO .3 3 t. 1. U\3 <br /> ample Rawlt: IXE 1000 100 10 <br /> 4AXIMLIM ALLOWABLE TPN LEVELS (PPM) <br /> t'7OO&AV TPN IESEL 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 atrrentty on UGT Contamination List for soil or ground water.) <br /> \1 If depth is > S ft. and < 25 ft., score 0 points. If depth "S ft., do not use tab(e. <br /> \2 If precipitation is > 40 Inches, score 0 points. <br /> \3 Levels for BTXU ore not appticabte at a TPN concentration of 10 ppm (gasotine) or 100 ppm (diesel). <br /> It. STAFF RECOMMENDATION/CONCLI)SION <br /> D <br /> 1. Are BTX ><E or TPN Concentrations > Allowable tevets es o r7' <br /> 2. Reammssnd Site Closure iYes If Yes, Refer to Site Mitigation for Evaluation <br /> 'STI. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> rWITR STAFF RECOMMENDATION FOR CLOSURE ES EFERRED TO SITE NITtCATtON FOR EVALUATION ES <br /> AT9EFERRED / / ATE CLOSURE LETTER MAILEDFTOR <br /> EN 23 0o (UGTWCSHT)\5/90 <br />