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SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL A DIVISION ` <br /> 1. LOST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY Cx V e rl f ROfh t a r WEEPS CODE <br /> W <br /> "DRESS 3 (j 1 ar 5-i C ANK ID # / <br /> TANK S12E \ do IFUEL TYPE yiPSe i <br /> II. GENERAL SITE HISTORY <br /> Is permit current? ks o ermit # acility Status Code oc.Soil/GW Cont es 10 <br /> umber of Tanks at facility ge of Tanks(if available) IType of Tank ISteel I IFbrgl I ISngll Dual <br /> III. TANK HISTORY <br /> Was Tank tested? as IFailed precision test ? es o [f yes, give date(s) <br /> as a repair made to the tank system? 1Yas No t/Iif yes, What was repaired? <br /> as repair done under inspection? IYes I Yo ere soil samples analyzed? 1Yes I to I TXE I PH-G PH-D 11 b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown 1 10 <br /> Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .oil Samples Received 1Yas oepth toGround Water I I0 of/Year If C,1 6 verage Annual Precipitation N= 4 10-25 <br /> )n-Site Wells) IYes o umber 8 Type Irr 1 em I ub <br /> S 3core S core S Score <br /> istance to Wells) from Tank LS ft; O J ft; ft C 10 pts C pts C 5 pts <br /> 0 if 0 if 0 if <br /> R onditLon R ondition R ondition <br /> V. Site Feature . Leaching Potential Analysis 6 E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1.100 25.50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) I L) None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby Wells. At least 4ore than <br /> xlIxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS 6L + a S <br /> ample Result: (B©X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> 0 T X E B T X E <br /> fC71Q = MAXIMUM ALLOWABLE 0•T-%•E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> -ample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> at Lo NPH IESEL 10,000 1000 11 100 <br /> OOTNOTES: ***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 ST%8E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> i�g <br /> 8 E or TPH Concentrations > Allowable Levels Yes70 4/nd Site Closure es o 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 14.ES I I,, O EFERRED TO SITE MITIGATION FOR EVALUATION ES JO <br /> )ATE REFERRED / / ATE CLOSURE LETTER MAILED / / <br /> AME OF 3 <br /> :VALUATOR L <br /> EH 23 80 (UGTWKSHT)\5/90 <br />