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SAN JOAOUIN CCUNT*LIC HEALTH SERVICES/ENVIRONMENTAL HEALTH ( ON <br /> LOST 'WORKSHEET FOR SITE CLOSURE EVALUATION ) ATE <br /> '!E OF FACILITY ni� G�f�C�'� EEPS CODE -2 .2— <br /> AHK ID 0 V1 <br /> ANK SIZE //,/.�:: ? UEL TYPE JAL u,ti- <br /> GENERAL SITE HISTORY <br /> �Is permit current7 as o ermit p - acility Status Code �`� oc.Soit/GW Cont as o <br /> user of Tanks at facility Ilge of Tanks(if abrgl ngl Dual <br /> TANK HISTORY <br /> ens Tank tested7 as o ailed precision test 7 as o If yes, give date(s) / <br /> is a repair made to the tank system? as No T yes, what was repaired? <br /> 'as repair done under inspection7 If <br /> as o ere soil samples anal yzed7 es of PH-G H-D 1, <br /> b/EDS <br /> Yoe of failure/discharge atastrophic long-term leakage I verf ill n nown I ther: <br /> REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received as o epth to Ground Water of/Year & ; ve rage Annual Precipitation 4 0-25 <br /> Ll <br /> n-Site Well(5) es o umber 8 Type Irr an ub <br /> S core S core S core <br /> ristance to Wells) frau Tank ft; ft; ft C 0 Pts C pts C pts <br /> O if 0 if 0 if <br /> R ondition R condition R ordition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> imum Depth to groundwater from the Soil Sample (feet) >100 1-100 © 25-50\1 <br /> ctures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> .-rage Annual Precipitation (inches) xxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> r.-Made cond:its which increase vertical migration /�/y <br /> .f leachate (i.e., septic systems, water wells, ponds) None C Unknown resent <br /> 'IniWe site features: Recharge area, coarse soil, nearby wells. At least are than <br /> xxxx None ` me one <br /> COLUMN TOTALS» Z>TOTAL POINTS • /L + <br /> mingle Result: (87TX :E),,,)F, RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> ?ivB T X EM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. 711A�3= <br /> i <br /> Sample Result: PP h ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPR IESEL 10,000 1000 100 <br /> OGTHOTES: '••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 /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 levels for STXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppn (diesel). <br /> STAFF REC"ENDATION/CONCLUSION <br /> 1. Are BTX $ E or TPN Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o If as, Refer to Site Mitigation for Evaluation <br /> :1. REVIEW EVALUATICN - TO BE COMPLETED Si A SUPERVISOR/SENIOR <br /> „NCUR WITH STAFF RECCHMEHDATION FOR CLOSURE ES EFERRED TO SITE MITIGATION FOR EVALUATION ES <br /> pa TE REFERRED / / ATE CLOSURE LETTER MAILED <br /> LAME OF <br /> ;VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />