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SAN lOAOUIN COJNT7. .IC HEALiN SERVICES/ENVI RCNME4 TAL HEALTH OIC, o, ATE 2 Z y� <br /> UGST eiSHEET FOR SITE CLOSURE EVALUATION <br /> . ` D/N�. . /�Al EPSCCOE <br /> nME Of FACILITY /� N <br /> � ANK IO s <br /> nORESS � f //// �-7 <br /> IANX SIZE 9bJ ZS UEL TYPE o/ U /� �� 7 7Z <br /> II. C-cHERAL SITE HISTORY <br /> Is permit current? es a ermit Y <br /> acility Status Code oc.Soil/GV Cont es L <br /> o <br /> umber of ranks at facility g <br /> e Of Tanks(if available) Ype of Tank teal brgl ngl Dual <br /> 111. TANK HISTORY <br /> ns Tank tested? es o ailed precision test ? es ifo IF yes, give date(s), <br /> os a repair made tO the Conk sys temp es No f yes, what was repaired? <br /> 'as repair done under irspectiort es o ere Boit sang les analyzed? eso <br /> iXE PH-GI PH-0b/E0a <br /> type of failure/discharge atastrophic long-term leakage verfitl known lo <br /> ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FCR SITE DETAILS/COLLEC DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ,it Samples received es o epch to Gravid Vater of/Tear , <br /> verage Arvmual Preeip itation = 4 0-25 <br /> -Site Vell(s) es a urber b Type Irr an up S core 5 core 5 care <br /> istance to Vell(s) frac Tank ft; _f C; ft C pts C pts CpfPCs <br /> 0 if if O R ordition <br /> lhF. <br /> R and I Ord <br /> Site Feature - Leaching Potential Arelysis <br /> E 's met is me - s met <br /> 4inimMm Depth to grourdwacer from the Soil Sang le (feet) <br /> > 00 I-100 25-50\1 <br /> r roc tures in subsurface (applies co foo chills or moMntain areas) <br /> Unknown resent <br /> average Annual Precipitation (inches) sxxx :10 0-25 xxxxxx 26.40\2 <br /> -an-made conduits which increase vertical migration kn �resenc <br /> � f Leachate (i.e., septic systems, water wells, ponds) NOAH o <br /> Jnipue site tea cur es: Recharge area, coarse soil, nearby wells. I At a More than <br /> sxxx More one <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> ample Result:,^(e T X OR E) RANGE OF TOTAL POINTS 9 pHs or more 41 - 48 pts 40 pts o less <br /> q� Iv 01 3 T X E 3 T X E <br /> 8� 0 h'� L?fw MAXIMUM ALLOUASLE 3-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> amte Result: lyov SOLINE 1000 100 10 <br /> 1MUM AlL0UA8LE iPN LEVELS (PPM) 100 <br /> �L7 TP IESEL 10,000 1000 <br /> COTNOTES: If documented soil and/or ground water cortxoimtlon is present, do not complete the Leaching potmtist <br /> analysis. (I.e., site is currently on UGT Contamination List for soil or grovel caster.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <a5 ft., do not use table. <br /> _ \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for 3TXIE are not applicable at a TPH concentration of 10 ppn (gasoline) or t00 ppm (diesel). <br /> :. STAFF RECOMENOAT ION/CCNCLUSICU <br /> 1. Are 3TX 1. E or TPN Concentrations > Alla ble Levels Tea o <br /> 2. RecamM>erd Site Closure es o If Yes, Refer to Site Mitigation for EvaLUation <br /> 'I. REVIEW EVALUATION - TO 3E COMPLETED 3Y A SUPE7VISOR/SE4I <br /> ONCJR WITH STAFF RECCMME40ATION FCR CLOSURE SES EFERRED TO SITE HITIGATICN FOR EVALUATICN MES 0 <br /> )ATE REFERRED / / TE CLOSURE LETTER MAILED y / <br /> uME Of <br /> ;vawatca <br /> EN 23 30 (UGTVXSHT)\5/90 <br />