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SAN JOAQUIN CCUNTYC HEALTH SERVICES/ENVIRONMENTAL HEALTH DI N <br /> UGST SHEET FOR SITE CLOSURE EVALUATION ATE 1 )-12- / <br /> "E OF FACILITY "">>5 c>Y� Gt.f/ .���j f1/] EEPS CODE I C 7 <br /> ORESS2 ��� jj� - ��l.Q;-C ANK ID X <br /> NK S12E UEL TYPE . I In/ q <br /> GENERAL SITE HISTORY <br /> s permit current? as o ermit 0 acility Status Code oc.SoiL/GW Cant as !o <br /> "r of Tanks at facility ge of Tanks(if available) ype of Tank teal I 1Fbrq1 ngl Dual <br /> I. <br /> TANK HISTORY <br /> ❑s Tank tested? as o ailed precision test ? as o If yes, give date(s) <br /> as a repair made to the tank system? as No 11f yes, what was repaired? <br /> ns repair core under inspection7 Ires I No are soil samples analyzed? as to TXE PH•G PH•D b/E06 <br /> vpe of failure/discharge atastrorhic long-term Leakage verfill I noun Cher: <br /> REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground 'Water of/Tear ve rage Arcwal Precipitation - 4 10-25 <br /> n-Site 'WeL((s) es o umber & Type Irr on b <br /> 5 core S Score 5 Score <br /> istance to WeLL(s) from Tank ft; ft; ft0 pts C pts C pts <br /> -0 -f 0 if 0 if <br /> R ondi tion R condition R ondition <br /> site Feature - Leaching Potential Analysis rs mer E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25.50\I <br /> ractures in subsurface (applies to foothills or :mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxxxx 26.40\2 <br /> nn-Made carduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) Nple Unknown resent <br /> :pique site features: Recharge area, coarse soil, nearby wells. At Least lore than <br /> xxxx None we one <br /> COLUMN TOTALS>»TOTAL POINTS <br /> ample Result: IS T X OR E) RANGE OF TOTAL POINTS 9 Pts or more 41 48 pts 40 PCs or less <br /> G I T X E 3 T X E <br /> MAXIMUM ALLOWABLE 3-T-X•E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> ample Result: SOU NE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> CGTNOTES: *'•If documented soil and/or ground water contamination is present, do not complete the Leaching potential <br /> aria lysis. (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 425 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXSE are not applicable at a TPH concentration of 10 ppn (gasoline) or 100 ppm (diesel). <br /> STAFF RECOMMENDATION/CCNCLUSICN <br /> I. Are 3TX 3 E or TPH Concentrations > Allowable Levels Yes o <br /> f <br /> Z. Recommend Site Closuree4 o If Yes, Refer to Site Mitigation for Evaluation -f 1'7% <br /> REVIEW EVALUATION - TO 3E COMPLETED BY A SUPERVISOR/SENIOR ( 'G jC S <br /> CNCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION InES 10 <br /> AiE RE FERR EC �Arr CLOSURE LETTER !AILED / / <br /> :AL'UAi <br /> 23 <br />