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SAN JOAQUIN CC n r PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL, VISION <br /> I L WORKSHEET FOR SITE CLOSURE EVALUATICH ATE <br /> AHE Of FACILITY I <br /> `L / /,+ 7 EEPS CODE L <br /> OORESS 7 ( I fi(�Jf T/` Yl� ANK ID X 3 C1 Q <br /> TANK SIZE �� DD(� UEL TYPE no r - <br /> If. GENERAL SITE HISTORY <br /> IS per it current? es o ermit - acility Status Code oc.Soit/GW Cont es <br /> 0 <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank tee? Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? , es o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repaiEda�ne nder inspection? es o ere sail samples analyzed? eso TXE PH-G PH-0ype of faischarge atastrophic long-term leakage verfill nknown Cher: <br /> iV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Fail Samples Received es o epth to Ground Water b of/Year ; verage Annual Precipitation = 4 0-25 <br /> Site Wett(s) 1Y <br /> eso umber 8 Type lrr om ub <br /> S core S care S core <br /> istance to Well(s) from Tank ft; ft; t ft C 0 pts C pts C pts <br /> 0 if 0 if 0 f <br /> R ondition R ondition R ondition <br /> `✓. Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> rinirxm Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Amual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e-, septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least are than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS ' ! G �j<�( <br /> ample Result: (8 T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> P'i 13 �.� ?reN B T X E 8 T X E <br /> - ,l MAXIMLkt ALLOWABLE 3-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA <br /> ample Result: _ ASOIINE1000 100 10 <br /> TAX' <br /> IMUM ALLOWABLE TPN LEVELS (PPM) _ <br /> 120 2n TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the teaching potential <br /> analysis. (i.e., site is currentty on UGT Contamination List for soil or ground water.) <br /> \1 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 BTXBE are not applicable at a TPH concentration of 10 plan (gasoline) or 100 ppm (diesel). <br /> Vi. STAFF R£CCFPIENOATICN/CONCLUSION �Z,y „ `"„`,� ._ n�) /►) r� <br /> 1- Are 3TX & E or TPH Concentrations > Allow le Levels Yes o {1 1 P .`(yl�e# <br /> t' 0. k <br /> 2. Rec--mend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> fli. REVIEW EVALUATIC44 - TO BE CCMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR VITH STAFF RECOMMENDATION FOR CLOSURE ES 0 1, <br /> EFERRED TO SITE MITIGATION FOR EVALUATICN ES 0 <br /> ATE RE=,RREO / i /C / ATE CLOSURE LETTER MAILED / / <br /> SAME OF / l <br /> :VAIUATCR <br /> EH 23 80 (UGTWXSHT)\5/90 <br />