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er SAN JOAQUIN CCA' PUBLIC HEALTH 3ERV1et5/tNV4KVKmr"3r&. ncz •� ATE <br /> WORKSHEET FOR SITE CLOSURE EVALUATION 7 " <br /> OF FACILITY WEEPS 000E !S <br /> -Arlo 9D <br /> FseII1ty flatus Cods DocsoiE/G11 tont Yes >ro <br /> oie wal T00 b _ Nish/ - o a <br /> NkislNl� of TO*$ at facility Aoe of 3anksCIf wsttabLe) C2 Type of Tank Sleet Fbryl ' Sngt Dust <br /> TAX9 NtSTORY ' <br /> 1 was Tank tested? Yes No Failed precision test T Yes No If yes, give dates) 7/ (p I rP <br /> l <br /> 1 1 <br /> Was a repair :made to the tank system? Yes Na If yes, what was repaired? <br /> was repair done under inspection? Yes No Were soil samples anatyzed7 Yes No BTXE TPH-G TPH-D Pb/E08 <br /> Type of failure/discharge catastrophic long-term Leakage overfill unkno+au other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS)] <br /> 1 Soil Samples Received Yes No Depth to Ground Waterb O Ref/Yeas F& ; Average Annual Precipitation A= 14 10.25 { <br /> On-Site WeLL(s) Yes No Number & Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to WeLL(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if O if <br /> R condition R condition R condition <br /> J# V. Site Feature - Leaching Potential Analysis &0(— E is met E is met E is met <br /> I Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> 1xx <10 9 10-25 xxxxxxx 26-40\2 <br /> Average Annual Precipitation (inches) <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water welts, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> � xxxxxx Hone one one <br /> COLUMN TOTALS»>TOTAL POINTS j d + t 1 .5 '3 + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> i n1 B T % E 8 T X E <br /> MAXIMUM ALLOWABLE 9-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> ry �r MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 1�f TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented Boit and/or ground water contamination is present, do not complete the Leaching potential <br /> r , anatysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> %I 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. <br /> `a <br /> \3 Levels for BTX&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> I. Are BIX & E or TPH Concentrations > Allowable Levels *Yes X jNoj <br /> F 2. Recommend Site Closure Yes No <br /> if Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> >: DATE REFERRED / / DATE CLOSURE LETTER NAILED <br /> =: NAME OF r_ <br /> EVALUATOR # w <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> J <br />