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SAN JOAOUIN VMkTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEkLl-PWIVISICN <br /> i UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE I / <br /> AME OF FACILITY , ECCRD 10 <br /> DORESS I s' ANK ID x - <br /> •RNK SIZE IIDO UEL TYPE I � ����ff � P <br /> ii. CE14ERAL SITE HISTORY �� "r <br /> is permit current? es o ermit R - aciIfty Status Code oc.Sofl/GW Cont es T o <br /> Nlmber of Tanks at facility ge of Tank(if available) � � IType of Tank feel Fbrglngl Dual <br /> III. TANK HISTORY <br /> I:as Tank tested? es o ailed precision test ? Ires o If yes, give date(s) y )'--20 <br /> !'as a repair made to the tank system? es 110 f yes, what was repaired? <br /> Was repair done under inspection? �esl No �ere sail samples analyzed? es I o TXE I PH-G PH-0 b/EDB <br /> Type of failure/discharge atastrophic I long-term leakageI,verfilE own they: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> � oiL Samples Received Yes o pepth to Ground Water Q of/Yearl� verage Annual Precipitation = I14 0-25 <br /> Cr,-Site Well(s) IYes o dumber & Type Ilrr fon <br /> f 5 Score 5 Score S core <br /> istance to WeLL(s) from Tank ft; ft; ft C 10 pts C 9 pts C <br /> pts <br /> 0 if 0 if 0 'f <br /> R ondition R ondition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> Minimum Depth to groundwater from the Soil Sampie (feet) }5 >i00 I1-100 I 125-50\1 <br /> Irac_ures in subsurface (applies to foothiLts or mountain areas) t a None Unknown resent <br /> �verage Annual Precipitation (inches) <10 I 9 110-25 xxxxxxx I26-40L <br /> an-Made conduits which increase vertical migration <br /> of leachate 0.e-, septic systems, water wells, ponds) None Unknown resent <br /> !,tnicue site features: Recharge area, coarse soil, or wells. /; I At least ithan <br /> i (M r.cipal=>2000 ft; domestic--->500 ft; irr/agricultural=present] Rene Yt one I <br /> -T- �- r a /. x rte, �► <br /> �COLUMN TOTALS—TOTAL POINTS x� + l +Sa L Result: (B T X OR "E) RANGEE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 ptr t 2a MAXIM M ALLOWABLE B-T-X-E L.EVELS (PPM) 1 50 50 50 .3 .3 1. Na <br /> �ASOLINE 1000 100 IMUM ALLOWABLE TPH LEVELS (PPM)S 1 GP p� TPH IESEL 10,000 1000 1 <br /> FOOTNOTES: * If documented soil and/or ground water contamination is present, do not complete the lea potent' <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water. <br /> L 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 /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> Vt. STAFF RECOMMENDATION/CCNCLUSI0K rn?B� ock��%�� P1a- bQ-ck <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o _)_ C�y �AQ„/_•dam <br /> 2. Recommend Site Closure es I oIf Yes, Refer to Site Mitigation for Evaluation rJ J`s 2—1K7/—Y I T77 Z e <br /> vti. REVIEW EVALUATION - TO BE CCMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> CNCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFEERRED TO SITE MITIGATION FOR EVALUATION ES f 0 <br /> AT_ REFERRED / bATE CLOSURE LETTER MAILED I <br /> I <br /> NAME OF <br /> VALUATOR <br /> -4 23 80 (UGTWKSHT)\5/94 <br />