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�✓ v <br /> SAN JOAQUIN dTY PUBLIC HEALTH SERVICS/M VIRON ENTAL HEP- DIVISION <br /> '•• yUST WORKSHEET FOR SITE CLOSURE EVALUATION A� ( C� <br /> ME OF FACILITY I >�mOrtIRE= ID <br /> 6ORESSI �� V\1 � ^ ANK ID13S - ISD(0 2/-�3 <br /> AMK SIS + (�C,c1��a rrn I d <br /> rr <br /> GENERAL SITE HIST 1 <br /> s mrmi t current? es a X rrai i s - aci l i ty status Code l j .Soi 1/GN Cont �Yf o <br /> �uaxr of Tanks at facility I U Ilge of Tank(if available) uhype of Tank k teel t �wVL Mat <br /> III. TAMK HISTORY <br /> s Tanis tested? fes I �o I ailed precision test ? les o f yes, give date(s) <br /> s a repair made to the tank system?! es I Mo 11f yes, what was repaired! <br /> -1 Mznwn� <br /> Gas repair done under inspection? fes �io �_M Boit samples uatyzed? es TXE I �PH-G <br /> �fy;,e of failure/discharge L tastrophicl ong-term leakage �vKfItt !her: <br /> -V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Poi! Samples Received fes o I depth to Grand Nater icy ef/Yeer Itverage Annual Precipitation I3= 4 �0-5 <br /> Pr <br /> -Site Ne t l(s) IYes IX �o I Doer i Type �I rr I ca <br /> S re 5 care 5 e <br /> Dis:ance to WeiL(s) from Tankl <�ft; f; ft C 0 pts C P pts C <br /> Pts <br /> 0 f 0 if 0 f <br /> R audition R itian R ordition <br /> .U. Site Feature - Leaching Potentia! Analysis E s met C is met E rs met <br /> Mini= Depth to grouncuater from the Soil Sample (feet) >100 � �1-100 � � 125-50\1 <br /> , <br /> Fractures in subsurface (applies to foothills or mountain areas) None C{ i Unknown present <br /> I <br /> Average Annuat Precipitation (inches) cuu= I <10 I 9 i 10-25 25-40_U <br /> Han-made concuits whicn increase vertical migration <br /> of !eacnate (i.e., septic systems, water wells, ponds) Mone Unknown 3 <br /> onicue site features: Recharge area, coarse snit, or wells. At Least lore than <br /> ;r.%-^cipat=>2000 ft; domestie=30500 ft; irr/agricut turat=preseat] Moo,, Mone I orwe one <br /> MUMN TOTALS»>TOTAL MINTS <br /> Sawte Resutt: (B T X OR £) RAMM OF TOTAL POIMTS 9 pts or more I 1-1 - 48 pts I 40 pts or less <br /> IT IX 2(0 �S MAXIMLM ALLM ABLE B-T-X-f LEVELS CPPM) 6 50 50 1 50 .3E a 3 11. 1. MAU <br /> Samo t» IME 1000 100 10 <br /> OWAXIKM A LOIJAB E TPH LEVELS (PPM) I <br /> IEM 10,000 ( low I 100 <br /> OOTMOTES: —If documented soil and/or grand water cantsinstian is present, do not complete the Leaching potential <br /> _togC'� analysis. (i.e., site is currantiy on LST Contamination List for soil or grand water.) <br /> L If depth is > 5 ft. and < 25 ft., score 0 points. If depth @5 ft., do not use table. <br /> s if precipitation is > 40 inches, score 0 points. <br /> ( ! x Levels for BTXLE are not applicable at a TPN concentration of 10 ppm (Smotine) or 100 ppm (diesel). <br /> :. STAFF RECOM4EADATION/CCMCLUSION <br /> Are BTX i £ or TPH Concentrations > Attowabte Levets es o <br /> 2. Recommend Site Closure a o If Yes, Refer to Site Mitigation for Evaluation <br /> REVIEW EVALUATION - TO BE C00LETED BY A SUPERVISORAEAD SENIOR <br /> I=MCUR WITH STAFF REC PME110ATION FOR M=RE S 1? �OTO SITE MITIGATION FOR EVALUATION �S <br /> PA REMRED I V / ✓L2 / S ATE M (SURE LETTER PKILED <br /> jtA.-f OF <br /> _VALUATOR , <br /> =H 23 80 CUGTWONT)\5/94 1 <br />