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SAN JOAOUIN JNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL Hl,�­,H DIVISION <br /> 1. <br /> LOST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 2.— 3 -� <br /> AME OF FACILITY WEEPS CODE <br /> DRESS �. 3 s, � P� � ANK ID # y- ZZ(p5 •O 1 <br /> ANK SIZE I'D UEL TYPE 0 <br /> 11. GENERAL SITE HISTORY <br /> M <br /> Is permit current? es o ermit # - aciLity Status Code oc.Soil/GW Cont es FT7 <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank teel t FbrgL ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o If yes, give date(s) <br /> Jas a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es o ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastroph is long-term Leakage verfiLl noun 1 10ther: <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 ef/Yea I jv ; `�'i. verage Annual Precipitation = 4 0-25 <br /> -Site WeLL(s) es o umber 8 Type Irr am Lb <br /> S Score S core S Score <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C pts C i pts <br /> 0 if 0 if 0 if <br /> R condition R ondition R ondi tion <br /> 1. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimxm Depth to groundwater from the Soil Sample (feet) SZ_g; >100 1-100 .J 25-501 <br /> Fractures in subsurface (applies to foothills or mountain areas) /t; None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxxxx 26.40 2 <br /> Ian-Made conduits which increase vertical migration <br /> f Leachate (i.e., septic syst ams, water wells, ponds) I None Unknown resent <br /> nique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxx None ,` one one <br /> COLUMN TOTALS>>>TOTAL POINTS 2& + l p + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B 1 TX E B T % E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> Sample Result: ( SOLINE 1000 100 10 <br /> a A QW.0 IMUM ALLOWABLE TPH LEVELS (PPM) <br /> ' l' TPN y;' IESEL 10,000 1000 100 <br /> OOTNOTES: ***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 /> 1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> L If precipitation is > 40 inches, score 0 points. <br /> L Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPM Concentrati onus > Allowable Levels Yes o <br /> l2. Recommend Site Closure�es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BECOMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 I EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT 5/90 <br />