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SAN JOAQU -,'?TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL <br /> [ 7IVISICN <br /> a— UST 'WORKSHEET FOR SITE CLOSURE EVALUATION �~ <br /> NAME OF FACILITY i EA <br /> NOORE55 I 7 ECORD ID <br /> S'7;,,-- ANK ID T <br /> ARK SIZE Q// / 6:_ UEL TYPE I Gfi/D <br /> f!. GENERAL SITE HISTORY <br /> Is permit current?Ses �01 ermit7;ype <br /> e2te- <br /> oc.fFbrgt <br /> l/GW Cantescumber of Tanks at <br /> p9e of 7ank(ifEavaiLjabLje) 7Tank Ingl Dual <br /> [[!. TANK HISTORY <br /> as Tank tested? fes I �lo I ailed precision11 t11 est ? es k !H( I <br /> I + 0 If yes, give date(s) <br /> f yes,1. wh <br /> at <br /> �:as a repair made to the tank system? es I No <br /> was repaired? <br /> Nas repair done under inspection? les �o ere soil samp[es anal <br /> ' yzed? es oI TXE I PH-G PH-O � b/EDB <br /> Type of failure/discharge ' ratastrophicI long-term leakage verfill <br /> own ther: <br /> !V. REMOVAL HISTORY (ATTACH I11 NSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oiL Samples Received fes <br /> opepth to Ground Water of/Year c^� <br /> Y7 verage Annual Precipitation �= 4 0-Z <br /> pn-Site Well(s) Yes I �O I dumber & Type Irr I qm I — <br /> is:-Ince to WeLL(S) from Tank ft; —ft; S care S core S core <br /> ft C 0 pts C <br /> 0 .f Pts C <br /> 0 if 0 -rp_s <br /> t!. Site Feature - Leaching Potential Anal R ondition R ondition R <br /> Analysis ondition <br /> E s met E <br /> is met a <br /> :!inimum Depth to groundwater from the Soil Sample (feet) his met <br /> �51-100 I �c 25-50\ <br /> Frzc:ures in suur-,"ace (applies to foothills or mountain areas) <br /> INOne Unknown present <br /> overage Annual Precipitation (inches) <br /> xxxx I <10 9 110-25 �xxxxxxx 25-40\2 <br /> bMan-Mace conduits which increase vertical migration <br /> f Leachate (i.e., septic systems, water wells, ponds) <br /> Lnicue site features: Recharge area, coarse soil, or wells. Unknown resent <br /> CMLnc4pat=>2000 ft; domestic=>500 ft; irr/agricultural=present] At least More than <br /> X 19one � one I <br /> one <br /> COLUMN TOTALS>>TOTAL POINTS 3� <br /> ampte Result: (B 7 X OR E) + d/ <br /> /3 -401r44u% RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts <br /> cow, I 40 pts or less <br /> s r x <br /> iJ.�.- MAXIMLIi ALLOWABLE B-T-X-E E B T X E <br /> LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. HA�3 <br /> ample Result: <br /> 11.11 i •Z�go.WW rP�-F' IMUM ALLOWABLE TPH LEVELS (PPM) LINE 1000 100 10 <br /> 4 TPH_/) IESEL 10,000 loco — <br /> 100 <br /> OOTNOTES: '"•"WIf documented soil and/or ground water contamination is present, do not c�l <br /> analysis. 0.e-, site is currently on UG. Contamination List for soiloregroundthe ewater.)achig �t�tiai <br /> 11 If depth is > 5 ft. and < 25 ft., score 0 points. If depth c=5 ft., do not <br /> �2 If precipitation is > 40 inches, score 0 points. use table. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> Vi. STAFF RECOMMENDATION/CCNCLUSIon <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levelr s �� <br /> Levels Yes o4_ 9��h ce_- 41.3/A <br /> 2. Recommend Site Closure es x <br /> o If Yes, Refer to Site Mitigation for Evaluation _ S//`� <br /> VI?. REVIEW EVALUATION - 70 BE COMPLETED BY A SUPERVISOR/LEAD SENIOR 2 ZPiGt <br /> CUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 <br /> EFERRED 70 SITE MITIGATION FOR EVALUATION �ES <br /> 0 <br /> LrArEEREFEIRREDL / ATE CLOSURE LETTER MAILED <br /> .l 23 30 (UGTWKSHT)\5/94 <br />