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JBLIC HEALTH SERVICES/ENVIRONMENTAL SION <br /> SAN JOACU ATE --z-t;' ' <br /> WORKSHEET FOR SITE CLOSURE EVALUA7I^�. <br /> I. �(� <br /> WEEPS CODE I 13`T <br /> PME OF FACILITY OJILD <br /> TANK ID # <br /> DOP.ESS O <br /> LANK SIZE UEL TYPE <br /> IT. GENERAL SITE HISTORY <br /> Is permit current? es o <br /> ermit # - acility Status Code oc.Soii/GW Cont es ✓ o <br /> cumber of Tanks at facility 9rA <br /> e of Tanks(if available) iq ¢ ype of Tank Leel rgl n9l Oual <br /> Ill. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o if yes, give date(s) �/ / j /z( / `J C7 <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> 'as repair done under inspection? es o ere soil samples analyzed? es o TXE PH_G PH-D b/E08 <br /> ype of failure/discharge atastrophic long-term leakage verfi(l nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSP CTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water j C) of/Year /L; verage Annual Precipitation = 4 0-25 <br /> :)n-Site Wel1(S) es 0 a umber & Type Irr cin ub <br /> S core S core S core <br /> istance to Wells) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 if 0 if 0 f <br /> R ondition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> 25 <br /> inimum Depth to groundwater from the Soil Sample <feet)yj a -j I <br /> >100 1-100 -50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) + None ]Unknown resent <br /> xxxxx <10 <br /> verage Annual Precipitation (inches) 910 25 xxxxxx 26 40\2 <br /> an-Hade conduits wflich increase vertical migration G Unknown Dresent <br /> f leachate (i.e., septic systems, water wells, ponds) None <br /> At le <br /> pique site features: Recharge area, coarse soil, nearby wells. least ore than <br /> xxxx None one one <br /> COLUMN TOTALS>>TOTAL POINTS 0 + + It d_ <br /> ample Result• (B T:XOR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> 3 ai�� �� B T X E B . T X E <br /> J ' MAXIMLH ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> ASOLINE 1000 `r 100 10 <br /> ample Result: <br /> AXIHUM ALLOWABLE TPH LEVELS (PPM) <br /> qjj, `\ TPH IESEL 10,000 C1000 100 <br /> COTNOTES: ***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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECCbWENOATION/CONCLUSION <br /> 1. Are BTX &. E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o if Yes, Refer to Site Mitigation for Evaluation <br /> "Ili. REVIEW EVALUATION - TO BE CCMPLETED BY A SUPERVISOR/SENIOR <br /> "ONCUR WITH STAFF RECCFIMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> )ATE REFERRED / / ATE CLOSURE LETTER MAILED / / <br /> SAME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />