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k SAN JOAQ1IN CAWPUBLIC NEALTN SERVtCES/ENVIRONMENTAL MEALTIIAVIStON <br /> I, UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> OF FACILITY �� S EPS CODE 2 <br /> R <br /> E �� , 10 <br /> SIZE AR:L TYPE r �' ` <br /> II. GENERAL SITE HISTORY " _�� <br /> rr <br /> s permit curreatt Yes o rmit B - scility Status Code oc.Soil/GW Cont es <br /> r of Tanks at facility kgo of Tanks(if available) ype of Tann teal I IFIrst-1 t I Dual <br /> I11. TANG HISTORY <br /> Ms Tank tested? es o sited precision test T es o if yes, give date(a) <br /> Jos a repair made to the tank system?IYes, Ho f yes, what was repaired? <br /> s repair dam under inspection? es 1 40 Part soil samples analyzed? es I o I TX£ I PH-G PH-D EDB <br /> ype of failure/discharg* tastrophicLong-term Leakage fill ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> it Samptes Received as th to Ground Water of/Year ; verage Annual Precipitationr�4 �0-25-Site Wells) es o r L Type IrrS ore S core S istance to Wells) from Tarek ft; ft; ' ft C 0 pts C pts C 0 f 0 if 0 R andition R ondition R Site Feature - Leaching Potential Analysis E s met E is met E <br /> inieum Depth to groundwater from the Soil Saeple (felt) r0 >100 1-100 25-5011 <br /> ractures in subsurface (applies to foothills or mountain areas) None , Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX CIO 9 10-25 Kxxxxxx 26-40.0 <br /> 4an-Made conduits which increase vertical migration <br /> f leadute (i.e., septic system, water waits, ponds) J V None Unknown resant- <br /> ique site features: Recharge area, coarse soft, nearby wells. (� At least re than <br /> None —I one /`� one <br /> MUM TOTALS>»TOTAL POINTS kQ <br /> + 7 + lJ 477 <br /> le Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> 00 7-t-r' BT X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 <br /> 150 <br /> SO SO .3 3 1. 1. NA.0 <br /> le Result: INE 1000 100 10 <br /> NIMUM ALLOWABLE TPN LEVELS (PPM) <br /> LPH IESEL 10,000 1000 100 <br /> OOTMOTES: *"If docueented 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 soft or ground water.) <br /> 11 If depth is > S ft. and < 25 ft., score 0 points. If depth "S ft., do not use table. <br /> If precipitation is > 40 inches, score 0 points. <br /> Levels for BTX&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECC#IENDATION/CONCLUSION ,. <br /> I. Are BTX i E or TPU Concentrations > Allowable Levels Yes o <br /> 2. Reca wend Site Closure es if Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> WITH STAFF RECO MEIDAT[ON FOR CLOSURE ES FEARED TO SITE MITIGATION FOR EVALUATION ES <br /> ATE REFERRED cam/ / TE CLOSURE LETTER MAILED <br /> EM 23 80 (UGn+KSMT)\5/90C1 S l/ _4 e re <br />