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SAN JOAQUINOUC NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> r' I UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACI — '' ^^ WEEPS CODE I <br /> DRESS IOZ STW <br /> . � ANK ID <br /> ANK SIZE UEL TYPE RFr� <br /> II. GENERAL SITE HISTORY .R <br /> Is permit current? es o efmlC # - acuity Status Code 9q oc,Sol L/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) UK- ype of Tank teal Fbrgl rgl Dual <br /> III. TANK HISTORY In `✓I " <br /> Jas Tank tested? es o ailed precision test T es o If yes, give dates) <br /> as a repair made to the tank system? Yes No f yes, what was repaired? <br /> as repair done under inspection? as No ere soil saiples analyzed? es o T%E lPH-G PH-D b/EEO <br /> ype of failure/discharge atastrophic long-teen leakage verfiLL nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAI OLLECT DATA F H POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water of/Year fin ; � erage Annual Precipitation <br /> -Site Well(s) es o umber 8 Type Irr an ub <br /> 5 core S core S core <br /> istance to WeIIts) from Tank ft; ft; --f t C 0 pts C pts C pts <br /> 0 f 0 f 0 if <br /> R onditi on R and it ion R onldi ti on <br /> J. Site Feature - Leaching Potential Ara lysis E is met E is met E is met <br /> ini mum Depth to groundwater from the Soil Sample (feet) >100 1-100 5 25-501 <br /> Fractures in subsurface (applies to foothills or mountain areas) None -t Unknown resent <br /> Average Annual Precipitation (inches) xxxxx <10 9 10-25 xxxxxx 26-401 <br /> Man-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown 5 resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxxx None �7_f one one <br /> COLUMN TOTALS>»TOTAL POINTS Z�- ' 3'T <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B <br /> F^•�- MAXIMUM Ml1M ALLOWABLE B-T-%-E LEVELS (PPM) 1 50 SO 50 .3 .3 1. 1. NAJ3 <br /> ample Result: ASOLINE 1000 100 10 <br /> I� <br /> AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: "•if documented soil and/or ground water contamination is present, do not caaplete the leaching potential <br /> analysis. (i.e., site is currently on UST Contaaira tion List for soil or ground water.) <br /> L If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> 1 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 TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure 1Y <br /> es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR RICH <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE E 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED 9 / /v / /2, ATE CLOSURE LETTER MAILED / / <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKS 5/90 <br />