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SAN JOAQUIN CC( PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA.` 'VISION <br /> I' N,,,v WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME Of FACILITY �-f c- o . OWSWEEPS CODE <br /> t��)'Cr <br /> ODRESS l O J TANK 10 # - / <br /> 3 or <br /> LANK SIZE UEL TYPE e /21 <br /> v <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es o ermit f! acitity Status Code oc.Soil/GW Cont es G <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank Leel I Fbrgt ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precis i test ? es o If yes, give dates) (1/f 6 /96; f / / 7 <br /> Jas a repair made to the tank system? 1Yes yHo f yes, what was repaired? <br /> Jas repair done under inspection? es 40 ere soil samples analyzed? es o ITXE PH-G PH-0 b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill I nknown Cher: i jh <br /> 1V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Solt Samples Received es I IHOI epth to Ground WaterO /Year � ; verage Annual Precipitation <br /> -Site Wett(s) Ires o umber d Type1 . 11r om ub <br /> S core S Score S core <br /> istance to Wett(s) from Tank ft; ft; ft C 0 pts C P pts C pts <br /> 0 if 0 if 0 f <br /> R ondition R ondition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Solt Sample (feet) >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) j None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 Kxxxxxx 26-40\2 <br /> Ian-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown >resent <br /> ique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS Q / (� 5 33 <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 I T X E B T X E <br /> MAXIMLH ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> oOTHOTES: ***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 STXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECCWENDAT ION/CONCLUS ION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels FeTs <br /> o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE CCMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> SAME OF <br /> .VALUATOR <br /> E23 <br /> 80 (UGTtlKSHT)\5/90 <br />