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SAN JOAQUIN COLPUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL' (VISION <br /> 1. U` WORKSHEET FOR SITE CLOSURE EVALUATION ATE q <br /> AME OF FACILITY / jC)�. -Qh" WEEPS CODE <br /> DRESS Oq [TANK 10 X <br /> TANK SIZE 0(nC UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> •e <br /> Is permit current? es o ermit p - acility Status Code oc.Soi L/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) IType of Tank teet Fbrgl ngl Dual ' <br /> 111. TANK HISTORY <br /> Jag Tank tested? es o ailed precision test 7 es o If yes, give date(s) <br /> Jas a repair made to the tank system? es No f yes, what was repaired7 <br /> Jas repair done under inspecti ont es o ere soil samples analyzed? es o T%E PH-C PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage vert ill noun 1 10Cher: <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/Yeab, verage Annual Precipitation 4 0-25 <br /> -Site WeIL(s) es I o I urber 8 Type I Irr 0n b <br /> S Score S Score S core <br /> istance to Well(s) from Tank ft; ft; ft C 0 pts C pts G pts <br /> 0 if 0 if 0 f <br /> R zondition R condition R ondi tion <br /> W. Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 S' 125-50\1 <br /> Fractures in subsurface (applies to foothills or mantain areas) None C Unknown resent <br /> Average Annual Precipitation (inches) xxxx <10 9 10-25 xxxx 26-40,L2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systcas, water welts, ponds) None I 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 <br /> ample Resglt: (B T X OR E)�O RANGE OF TOTAL POINTS 9 pts or more 1 - 48 P 40 pts or Less <br /> t1i .I1/ i <br /> B I T % E B T % E <br /> MAXIMUM ALLOWABLE S-T-X-E LEVELS (PPM) 1 50 50 50 .3 3 1. 1. NAL <br /> Sample Result: SOLINE 1000 100 10 <br /> G IMIM ALLOWABLE TPN LEVELS (PPM) <br /> 4+f TPH 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 LOT Contamination List for soil or ground water.) - <br /> 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 /> L3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMIENDATION/CONCLUSION <br /> 1. Are BTX E E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es1140 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 �EFERREO 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 />