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SAN JOAQUIN COUw PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTe_ ,VISION <br /> 1• U(-W WORKSHEET FOR SITE CLOSURE EVALUATION ATE 41 <br /> AME OF FACILITY 5 �CA._,(� �� WEEPS CODE /�7j� <br /> DRESS lT E .C.G-l�t'� U.fl` C�'r-"� <br /> �,.� ANK ID S <br /> ANK SIZE &(I( UEL TYPE n !� <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit k acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank teel Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested7 es o ailed precision test 7 es o If yes, give dates) <br /> Jas a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done order inspection? es I o ere soil samples analyzed? as o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic Long-term leakage verfill noun cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water (��; of/Year _ verage Annual Precipitation 4 0-25 <br /> -Site Weil(s) es o umber 8 Type Irr om ub <br /> S Score S Score S 3core <br /> istance to Well(s) from Tank ft; ft; ft C 10 pts C 9 pts C5 Pts <br /> 0 if 0 if 0 if <br /> R ondi tion R condition R ondi ti on <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 �1-100 25-5011 <br /> Fractures in subsurface (applies to foothills or mountain areas) Non Unknown lresent <br /> verage Annual Precipitation (inches) xxxx 00 9 10-25 xxxx 26-4012 <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 ore than <br /> xxxx None �� one one <br /> COLUMN TOTALS»>TOTAL POINTS * 36 <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 p s 40 pts or less <br /> -T - X E <br /> L' KAXIML14 ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: SOLINE 1000 100 10 <br /> C M IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPN 6 IESEL 10,000 1000 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 UGT Contamination List for soil or ground water.) - <br /> 11 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 RTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 porn (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are aTX d E or TPN Concentrati ors > Allowable Levels Yes o V <br /> 2. Recommend Site Closure es ✓ o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION . TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />