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_ SAN JOAQUIN t TY PUBLIC HEALTH SERVICES/EIIVIROHMENTAL HE1+Vrf,DIVISION <br /> iT WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AHE OF FACILITY EEPS CODEal G <br /> ODRESS <br /> ANK 51 Zf UEL TYPE ) <br /> Ill. GENERAL SITE HISTO Y <br /> Is .permit current? es o ermit 4 acility Status Code oe.Soit/CW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) Irype of Tank ISLeel Fbrgl I lsngtt <br /> Oual <br /> 111. TANK HISTORY <br /> Jas tank tested? es o ailed precision test 7 es o If yes, give date($) <br /> as a repair made to the tank system? es Ne 11f yes, what was repaired? <br /> 1s repair dare under inspection? es EtIng <br /> ere soil samples analyzed? es to TXE PM-G PH-0b/EDi3 <br /> ype of failure/discharge atastrophicterm`Leakage verfill Hawn Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oiI Samples Received es 1 o epth. to Ground Water 35, of/Year [N( ; verage Arcual Precipitation <br /> -Site WeLL(s) IYes ' o umber & Type IrrI. )cm b <br /> 5 Score S Score 5 core <br /> istance to Wells) from Tank ft; _f t; ft C 10 pts C 9 pts C pts <br /> 0 if O if 0 . f <br /> R rondition R condition 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 Sample (feet) I� r 1 r100 1.100 25-50\1 <br /> 4�� <br /> ractures in subsurface (applies to foothills or mountain areas) U Hone Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX 00 9 10-25 xxxxxxx 25-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None unknown S resent <br /> )nique site features: Recharge area, coarse soil, nearby wells. At Leastore than <br /> KXXXXii x None One one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> ample Result: (8 T X OR E) RANGE 'OF TOTAL POINTS 9 pts or more 41 48 .pts 40 pts or Less <br /> Ns T x E B x E <br /> MAXIi .M ALLOWABLE B-T•X-E LEVELS (PPM) 1 50 50503 I.T <br /> 3 1. 1. NA\3 <br /> Sample Result: LINE 1000 100 10 <br /> IALLOWABLE TPH LEVELS (PPM) <br /> S TPMUH H IESEL 10,000 1000 100 <br /> 007HgT£S: ••'If documented soil and/or ground water contamination is present, do not complete the Leaching potential <br /> analysis. (i.e.. site is currently on UGI Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and a 25 ft., score 0 points'. If depth c=5 ft., do not use table. <br /> \2 If precipitation is a 40 inches, score 0 paints. <br /> \3 Levels for BTXdE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1, Are BTX 3 E or TPH Concentrations > Allowable Levet Ro <br /> 2. Recommend Site Closurees o If Yes, Refer to Site Mitigation for Evaluation <br /> V11, REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> OIICUR WITH STAFF RECOMMENDATION FOR CLOSURE ES EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF " <br /> .VALUATOR 1 LAJ" <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />