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I. <br /> SAN JOACUIN Cal 1LIC 4EALTH SE1VICE3/ENVIRCNME4TAL 4EALTf ;ICN <br /> I. UGai ..LRKSHEET FOR SITE CLOSURE EVALUATICN ATE I <br /> nME OF FACILITY ( i' h!• C11 ! 7tGG l `-PS CODE <br /> n00RESS S: J S' ' `'` ANK ID x 3 <br /> (HANK SIZE / UEL TYPE �l�I +' /U� `G� _-• <br /> II. GENERAL SITE HISTORY <br /> Is permit current7 es o ermit - acility Status Code oc.Soil/GW Cont es IVo <br /> unber of Tanks at facility ge of Tanks(if available) `L � ype of Tank Leel Fbrgl ngl Dual <br /> III. TANK 4ISTCRY <br /> ms Tank tested7 es o ailed precision test 1 es o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> 'ns repair done under inspection? eso ere soil samples analyzed? es o TXE PH-G IYPH-D b/E08 <br /> Type of failure/discharge atastrophic long-term leakage rfill noun I lo <br /> ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FCR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water of/year ; verage Annual Precipitation = 4 0-25 <br /> Lis <br /> ite Well(s) es o ember b Type Irr cm ub <br /> S core S core S core <br /> ance to Welt(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ronditicn R condition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimtm Depth to groundwater from the Soil Sample <feet) LfO_ >100 I 1-100 I 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 t 9 10-25 xxxxxxx 26-40\2 <br /> an-Hade conduits wfiich increase vertical migration <br /> F leachate (i.e., septic systems, water wells, ponds) None Unknown Dresent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least ) ore than <br /> xxxx None one one <br /> CCLUMN TOTALS—TOTAL POINTS * + <br /> Sample Result/:: (8 T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> 8 T X E 8 JT X E <br /> MAXIMLH ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. 4A\3 <br /> Sample Result:r> ASOLINE 1000 100 10 <br /> l�I1 N 1/ AXTMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 1 10,000 1000 I 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently on UCT 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 3TXSE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECCbVENDATION/CCNCLUSION <br /> 1. Are 3TX & E or TPH Concentrations > Allow a Levels Yes o <br /> 2. Recommend Site Closurees o If Yes, Refer to Site Mitigation for Evaluation L a_d y 7 pp yyv <br /> VII. REVIEW EVALUATION - TO 3E COMPLETED 3Y A SUPERVISOR/SENIOR / J <br /> CONCUR WITH STAFF RECCHMERDATICN FCR CLOSURE IESI O EFERREO TO SITE MITIGATICN FOR EVALUATION ESI 0 <br /> ATE ,REFERRED / / ATE CLOSURE LETTER MAILED f % <br /> JAME OF <br /> ;VALUATOR <br /> EH 23 30 (UGNXSHT)\5/90 <br />