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SAN JOACUIN COUNTY -IC HEALTH SERVICES/ENVIRCHMENTAL HEALTH 0: ON <br /> UGSTZ7CRKSHEET FOR SITE CLOSURE EVALUATION ATE d_ <br /> nME OF FACILITY S �/ . / _k -/_fv SWEEPS CODE / 6 <br /> n0a£ss 3 b �T N./W LTANK to x <br /> TANK SIZEI UEL TYPE <br /> II, GENERAL SITE HISTORY <br /> Is permit current7 es o ermit x - acility Status Code �! x.Soil/GW Cant es o <br /> umber of Tanks at facility 9e of Tanks(if available) ype of Tank teel klFbrgL ngl I Dual <br /> III. TANK HISTORY <br /> ms sank tested? es o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> :ns repair done under inspecticnl iyes o ere soil samples analyzed7 IYes o TXE PN-G PH-0 b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received I es o epth to Ground 'dater of/Year verage Annual Precipitation = 4 11 <br /> 0-25 <br /> -Site Well(s) es I a I umber 8 Type I Irr cm ub <br /> S core 5 Score S Score <br /> istance to Well(s) from Tank ft; ft; ft C 0 pts C 9 pts C 5 pts <br /> 0 1f 0 if 0 if <br /> R ondi tion Rcard!tion R onditicn <br /> V. Site Feature - Leaching Potential Analysis E is met E is met Es met <br /> inimun Depth to groundwater from the Soil Sanpte (feet) >100 1.100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) Nme Unknown resent <br /> vcrage Annual Precipitation (inches) xxxxxx <10 9 10.25 xxxxxx 26.40\2 <br /> an-Hade conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) Rare Unknown resent <br /> niyue site features: Recharge area, coarse soil, nearby welts. At least fore than <br /> xxxx More one one <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> arole Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T X E <br /> MAXIMLIM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> ample Result: ASOLINE 1000 100 10 <br /> AX[M;M ALLOUAB LE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> COTNOLES: "'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., scare 0 points. If depth <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, scare 0 points. <br /> \3 Levels for STX8E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECCh44EN0ATION/CCNCLUSICN <br /> 1. Are BTX 8. E or TP4 Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> -ONCJR WITH STAFF RECCMMENDATICN FOR CLOSURE IES 0 EFERR ED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILEDy <br /> TAME OF <br /> :VALUATOR <br /> CH 23 80 (UGiw'KSHT)\5/90 <br />