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SAN JOAOUIN cc ' 1 IC HEALTH SERVICES/ENVIRONMENTAL HEAL RON r <br /> I . dw.:T SHEET FOR SITE CLOSURE EVALUATION ATE <br /> nHE OF FACILITY EPS CODE M D L 6 D <br /> OORESS 60 � /v C*ArLtgl/ " is `e ANK ID ? <br /> rANX SIZE UEL TYPE D�e$e/ Gwl - <br /> Il . GENERAL SITE HISTORY - <br /> Is permit current7 eso ermit # - acility Status Code S oc . Soil /GW Cont es o <br /> umber of Tanks at facility Be of Tanks( if available ) ype of Tank teel Fbrgl ngI Duet <br /> III . TANK HISTORY <br /> as Tank tested? as a ailed precision test ? as a If yes , give date( s ) <br /> as a repair made to the tank system? as No f yes , what was repaired? <br /> as repair done under inspection? as o ere soil samples analyzed2 es o TXE PH- G -0 b/EDB <br /> ype of failure/discharge atastrophic long- term leakage verfill known cher : <br /> - v . REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS ) <br /> ail Samples Received as aalo epth to Grouts Vater 130e of/Yeaverage Annual Precipitation = 4 0- 25 <br /> MMftMMftM <br /> Site WeIL (s ) es o umber d Type 11 r an b <br /> 5 Scare S core 5 3core <br /> istance to WeLL ( s ) from Tank ft ; ft; ft C la pts C pts C 5 pts <br /> - <br /> O if O if O if <br /> R ondition R ondition R ordition <br /> �. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimtm Depth to groundwater from the Soil Sample tfeet) > 100 1 - 100 s 25- 50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas ) None 4j' Unknown resent <br /> verage Annual Precipitation ( inches ) xxxx <10 9 10- 25 xxxxxxx 26- 40\2 <br /> on-Made conduits which increase vertical migration <br /> f leachate ( i . e. , septic systems , water wells , ponds ) None _ Unknown resent <br /> nicue site features : Recharge area, coarse soil , nearby wells. p At Least tore than <br /> xxxx More I we one <br /> COLUMN TOTALS>>>TOTAL POINTS l � * c� 7 S Y6— <br /> ample Resu <br /> lt : (B T X OR E ) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> 8 1 T % E B E <br /> a (a yv1 MAXIMLH ALLOWABLE B - T- X-E LEVELS (PPM) 1 50 SS 50 .3 3 1 . 1 . NA\3 <br /> ample Result : ASOLINE 1000 100 10 <br /> 3` y 00r" AXIMUM ALLOUABLE TPH LEVELS (PPM) <br /> IITPH —& IESEL 1 10, 000 1 1000 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 grovel 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 BTXBE are not applicable at a TPH concentration of 1 Jon <br /> (gasoline) or 100 ppm (diesel ) . <br /> I . STAFF RECCFWENDATION/[CNCLUSION /�� <br /> 1 . Are BT% $ E or TPN Concentrations > Allow le Levels Yes o <br /> I2 . Recommend Site Closure es o If Yes , Refer to Site Mitigation for Evaluation <br /> tli . REVIEW EVALUATION - TO BE CCMPLETEO BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECCHMENDATION FOR CLOSURE E5 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> TAME OF <br /> :VALUATOR <br /> IFF 23 BO (UGTUKS T ) \5/90 <br />