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SAN JOAOUIN ITY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE: DIVISION <br /> 1' I' WORKSHEET FOR SITE CLOSURE EVALUATION ATE 2 fJ/ <br /> AME Of FACILITY <br /> EPS CODE 7 <br /> ORESS <br /> �- _{ <br /> AUX SIZE <br /> 10 OE S-�jv FUEL TYPE <br /> It. GENERAL SITE HISTORY <br /> Es permit current? es o ermit Y - acility Status Code oo.Soil/Gw Cant •e's <br /> o, <br /> E1 <br /> of Tanks at facility ge of Tanks(if available) ype of Tank teel brgl '( Oust. _ <br /> 111. TANK HISTORY <br /> ns Tank tasted? as o ailed precision test T es o If yes, give date(s) <br /> s a repair made to the tank system? es No f yes, what was repaired? ^, <br /> J: <br /> as repair done under inspectienT es o ere soil samples analyzed? as o TXE PH-G PH-o 1ED8 <br /> Ype of failure/discharge acastrophic long-term leakage verfill la cher: <br /> IV. REMOVAL NiSTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LGiCIIING POTENTIAL ANALYSIS) <br /> it Samples Received as o epth to Ground Water of/Tear verag* Annual Precipitation ■ 4 0-25 <br /> -Site Well(s) es o umber t Type Irr as ub <br /> S core S Score S core <br /> istance to Wait($) from Tank ft; ft; ft C 0 pts C pts C es <br /> 0 f 0 if O fp <br /> R ondition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E 's met E is met E s mac <br /> inimum Depth to groundwater from the Soil Sample tfeet) 1100 1-100 O 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) Wane Unknown ressnt <br /> verage Annual Precipitation (inches) KXXXXX 110 9 10-25 x=x 26-40\2 <br /> on-Made conduits which increase vertical migration <br /> f leachate (i-s-, septic systems, water wells, ponds) None Unknown Present <br /> ique site features: Recharge area, coarse soil, nearby wells. At least 4are then <br /> [None one one <br /> COLUMN TOTALS»>TOTAL POINTS �U ♦ <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS9 pts or more 41 - 4a pts 40 pts or less <br /> 3 ,oOS Fri— g= W*7 <br /> e T X E 8 T Ix E <br /> r =OC3 r- HAXIMILM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 150 150 .3 .3 1. 1. NA\3 <br /> le Result: OLINE 1000 100 10 <br /> IMl1M ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: *"If documented soil and/or ground water contamination is present, do not complete the leeching 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 4.5 ft., do not use cable. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for &TUE are not applicable at a TPH concentration of 10 pps (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX !~ E or TPH Concentrations > Allowable Levels as 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 /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED 2L/ ATE CLOSURE LETTER MAILED <br /> TAME OF <br /> :VALUATOR <br /> EN 23 80 (UGTVKSHT)\5/90 <br /> 1 I, <br />