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f-� <br /> SAN JOAQUIN Y P28LHE(LTH �RlONMENTAL NEA DIVISION <br /> 1. �UG�ST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY EEPS CODE <br /> DDRESS v ANK iD # <br /> TANK SIZE ul TYPE <br /> 11. GENERAL SITE HISTORY .: <br /> Is permit current? es o ermit # acility Status Code oc.Soil/GW Cont es Jo <br /> umber of Tanks at facility ge of Tanks(if available) IType of Tank teel Fbrgl ngt Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o 1f yes, give date(s) <br /> as a repair made to the tank system? 1Yes No f yes, what was repaired7 <br /> ns repair done under inspection? es o ere soil samples analyzedl ITes to TXE -GT PH-0 b/EDB <br /> Type of failure/discharge atastrophic long-term teakage verfitt nknownther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water of/Year verage Amuat Precipitation = 4 10-25 <br /> m Site Well(s) es o umber 8 Type Irr om ub <br /> S Score S Score S Score <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1.100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) U None Unknown Dresent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> lnique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxxx None one S one <br /> COLUMN TOTALS» /6 <br /> >TOTAL POINTS ( v * / + ( t� <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> -ample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH 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 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 paints. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Arc BTX 8 E or TPH Concentrations > Allowable Levels Yes toi <br /> I2. Recommend Site Closure es o F71f Yes, Refer to Site Mitigation for Evaluation <br /> `.'I1. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE 'ES '0 EFERRED TO SITE MITIGATION FOR EVALUATION ES JO <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />