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�r <br /> SAN JOAOUIN TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAT IVISICN <br /> [ LIST WORM EE-T FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY ��� r 4L�C G CORK ID <br /> ARK [DTI - <br /> .YANK SIZE L TYPE a <br /> [ <br /> 1. .;EMERAL SITE HISTORY <br /> Is permit current? es �o ermit lFacitity Status Code IDoc.SoiL/GC7 Cont es o a <br /> t.Tber of Tanks at facilicyl nage of Tank(if available) �ype of Tank teal I ar'lsrgl ngl Dual I <br /> III. TANK HISTORY <br /> Las Tank testes!? ales I �Io I date <br /> (s) <br /> precision test ? -fes I �o� If yes, give dats) <br /> ! <br /> as a repair made to the tank system? es I No I f yes, what was repaired? <br /> as repair done under inspection? �es I 'ko Jere sail samples analyzed? les o I 1BTXE I J`PH-G I H-0 I h/EDB <br /> fvoe of failure/discharge r�atastro;hicI Mang-term leakages veritl I Cher: <br /> !V. IEMOVAL HISTORY (ATTACH INSPECTION REPORT FOR S17E OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received ayes I �o �epth to Graemd Vater of/Year average Annual Precipitation = I4 l)-zs <br /> j -Site Vel L(s) ayes a aVuriber & Type F 11r, �sxa I a I <br /> S care 5 Score 5 care <br /> istance to We(L(s) from Tank I ft; ft; ft C 0 pts C 9 pts C ass <br /> 0 r 0 if 0 f <br /> R ondition R ondition R rdition <br /> ?1. Site Feature - Leaching Pocentiat Analysis E s met E s met - his met <br /> Minimum Depth to groundwater from the Sail Saaale (feet) ��— >100 I 1-100 I � I2-5-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) a None I Unknown I resent <br /> 1 verage Annual Precipitation (inches) _ I <10 9 I i0-25 axxxx�ocx 125-40L <br /> tan-Made conduits wnich increase verticat migration <br /> i <br /> leachare (i.e., septic systems, water we(ls, Ponds) Kone unknoun resent <br /> Inicue site features: Recharge area, Coarse soil, or wells. At teasr are than <br /> i4uncipaL=>2000 ft; domestic=>500 ft; irr/agricut turalroresentl 11=1None one one <br /> COLUMN TOTALS»iOTAi POINTS <br /> 6amote [esul:: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more G1 - 48 pts I 40 pts or less <br /> }- <br /> evo���/ B TX B T X E. <br /> MAXIMUM E' LE <br /> ALLOWABLE B-T-X-E (PPM) 1 50 � 50 I <br /> 5"c0 .3 I.3 I <br /> 1. 1 � NA]3 <br /> ample Result: IHE 1000 IOa I 10 <br /> iMUM ALLOWABLE -e PN LEVELS (PPM) <br /> TPH IESEL 10,000 I 1000 100 <br /> CUTNOTES: —If documented sail and/or a'ou: water contamination is present, do nor comptere the teaching potential <br /> analysis. (i.e-, site is currentty an UGT Contamination Lisr for soil or ground water.) <br /> '+ 1 If depth is > 5 ft, and < 25 ft., scare 0 points. if depth <=i ft., do not use table- <br /> If precipitation is > 40 inches, score 0 points. <br /> L Levels for MME are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 p¢n (diesel). <br /> VI. STAFF RECOMMENDATION/CCNCLUSION <br /> ,�,,y�1 <br /> 1. Are M & E or TPH Concentrations > Allowable Levels es izs�ol <br /> ff• (�/„/�'el� �/�, f <br /> 2. Recommend Site Closure es o If res, Refer to Site Mitigation for Evaluation <br /> vi I. REVIEW EVALUATION - TO 3E C(]NPLETED 3Y A SUPERVISOR/LEAD SENIOR <br /> CNCUR WITH STAFF RE=MMENDATiON FOR CLOSURE E5 'o I Ir:FERRED TO SITE MITIGATION FOR 'EVALUATION �ES� 'I <br /> ATE REFERRED / -7 / 7 PATE CLOSURE'LETTER MAILED <br /> AME OF - <br /> VALUATOR L�/J <br /> E!'. 23 a0 (UGTWSHT)\5/94 <br />