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- SAN JOACUIN C dIIC HEALTH SERVICES/ENVIRONMENTAL HEAL - J 510 <br /> ATE C�=07 <br /> Gj <br /> llGa' ;;SHEET FOR SITE CLOSURE EVALUATION <br /> EEP5 CODE /65/ <br /> 5 <br /> AME OF FACILITY 1 /¢ <br /> J ANE( t0 # <br /> �ffDRESS L(f <br /> a <br /> IANK SIL -u+7D UEL TYPE <br /> fl. GENERAL SITE HISTORY *' ; <br /> Is permit current? es a ermsit X <br /> acility Status Code oc.Soit/GSa Cont. es o 1 <br /> umber of tanks at facility EeoETan s(If available} (�7' ` ype of Tank teeE hrgt ngt Duat <br /> 3 <br /> I 1 I. TANK HISTORY ' <br /> as Tank testees o ailed precision test 1 es o If yes, give date(s) <br /> d? <br /> as a repair made to he tank system? es Ho f yes; what wa repaireIn <br /> d? <br /> as repair done under inspection) es o ere sail samples analyxed7 es a TXE PH PH-D b/E08 <br /> Type of failure/discharge atastrophic tong-term leakage verfill known there <br /> TV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETA[LS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oit samples Received es H. <br /> epth to Ground Vater C/ of/Year G, 7 verage Annual Precipitation kz 4 0-ZS <br /> -Site uett(s) es o umber 1: Type Irr °�" ub S Score S Scare S core. <br /> istance to Wetl(s) from Tank ft; ft; ft C 10 pts C 9 pts C Pts <br /> 0 if 0 if 0 f <br /> R ;' ondition R ondition R audition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) 1 >to0 �' 1-100 25-50\t <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> %verage Annual Precipitation (inches) j Kxxxxi <t0 9 xxxxxxx 26-40\2 <br /> an-Made conduits %hick increase vertical migration '. <br /> F leachate (i.e.. septic systems, water wells, ponds) None Unknown resent <br /> ni:,ue site features: Recharge area, coarse soil, nearby welts. :1 At least ore`than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> 1 + + y <br /> amotc Result, (a T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> 1-,0 a Tj I X JEB JT X E <br /> )(= 7 3� �� MAXIMLH ALLOWABLE a-T-X-'E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. 4A\3 <br /> ample Result: SCLINE 5000 100 1U <br /> IKJH ALLOWABLE TPH LEVELS (PPM) <br /> TPH iESEL 10,000 1000 100 <br /> COTNOTES: ***If documented soil and/or ground water contamination is present, do not comptete the teaching 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 /> \Z If precipitation is > 40 inches, score :0 points. '-' <br /> \3 Levels for S WE are not applicable at.1a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> Vt. STAFF RECCM9MOAT ION/CCNCLUSION <br /> 1. Are 81X $ E or TPH Concentrations > Allowable Levels Yes o (f�l T <br /> 2. Recommend Site Closure es o If Yes, Refer, to Site Mitigation for Evaluation <br /> Vil. REVIEW EVALUATION - TO BE CCHPLETEO BY A SUPERVISOR/SENIOR <br /> CONCUR WITH'STAFF RECCHMENOW ON FOR CLOSURE E5 O i FEF--,;RED TO SITE NIT[dATION FOR EVALUATION ES C <br /> ATE REFERRED / / l Z ATE CLOSURE LETTER MAILED ' i / <br /> rAI+.E OF <br /> ;VALUATCR <br /> EH 23 80 (VGTUXSHT)\5/90 <br />