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SAN JOAQUIN CG ". PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL' "TV IsION <br /> I' WORKSHEET FOR SITE CLOSURE EVALUATION <br /> ATE <br /> AME OF FACILITY <br /> WEEPS CODE <br /> DRESS 00 C /I a; S <br /> �1v" <br /> AHK SIZE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es a ermit # - acility Status Code oc.Soil/GW Cont es: o <br /> umber of Tanks at facility ge of Tanks(if available) IType of Tank teeLT FbrgE I J-gt I Dual <br /> III. TANK HISTORY <br /> Jas Tank tested? eso ailed precision test 7 es o If yes, give dates) / / <br /> as a repair made to the tank system? 1Yes Na f yes, what was repaired? - <br /> as repair done under inspection? es o ere sail samples analyzed7 es o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verfitt noun they: <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 �'Vof/Year 1 verage Arcual Precipitation <br /> -Site Uett(s) IYes o umber & Type 11r am uio <br /> S Score S Score S 3care <br /> istance to Wett(s) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 if <br /> R rondirion R conditioh R ondition <br /> 1. Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sampte (feet) >100 �51-100 25-50L <br /> Fractures in subsurface (appties to foothills or mountain areas) . Hone 1 Unknown resent <br /> verage Annuat Precipitation (inches) xxxxxx <10 9 10-25 xxxAxxx 26-402 <br /> an-Made conduits which increase vertical migration e� <br /> f leachate (i.e., septic systems, water wells, ponds) None 1 Unknown 5resent <br /> �I <br /> pique site features: Recharge area, coarse soil, nearby wells. At Least lore than r <br /> xxxx Hone .7 one one <br /> � I <br /> COLUMN TOTALS» 0>TOTAL POINTS + * 0 �SO <br /> ample Result: (B T X OR E). RANGE OF TOTAL POINTS 9 pts or mo:� 41 - 4a pt: 40 pts-or tes <br /> T X E 8 E <br /> MAXIMUM ALLCWABLE B-T-X-E LEVELS (PPM) 1 50 50 SO .3 .3 1. 1. t NA]3 <br /> ample Result: SOLINE1000 100 10 <br /> `� I" ALLOWABLE TPH LEVELS (PPM) <br /> h� TPH IESEL 10,000 1000 100 j <br /> FOOTNOTES: **"If documented soil and/or ground water contamination is present, do not complete the leach'ng potential <br /> anatysis. (i.e., site is currently on UGT Contamination List for soil or ground Ovate <br /> L If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> L2 If precipitation is > 40 inches, score 0 points. <br /> _\3 Levels for BTX&E are not appLicable at a TPH.concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> YI. STAFF RECOMMENDATION/CONCLUSION �'+t OC�Af-S <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levets Yes o CL <br /> 2. Recoffaend Site Closure Yft o If Yes, Refer to Site Mitigation for Evaluation <br /> VIE. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES a EFERRED TO SITE MITIGATION FOR RALUATION ES_ <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />