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SAN JOAQUIN C4PUBLIC HEALTH SERVICES/ENVIROHMENTAL HEAL ' '[VES'OH <br /> I, WORKSHEET FOR SITE CLOSURE EVALUATli, ATE 3 <br /> AME Of FACILITY i }LpCIO 2 EEPS CODE } <br /> j <br /> rfDRESS ARK ID # <br /> TANK SIZE �r UEL TYPE Is <br /> It. GENERAL SITE HISTORY <br /> F. I5 permit current7 es o ermit # - acility Status Code; oc.Soil/GW Cont es ✓ o <br /> Ii i <br />} wnber of Tanks at facility -77 ge of Tanks(if available) I 1Wc !ype of Tankteel Fbrgt ngl I Ouat <br /> III. TANK HISTORY <br /> Is Tank tesied7 es o ailed precis test ? es o If yes,11give date(s) j`/ / �aq <br /> as a repair made to the tank system? es No f yes, what was repaired? IMNfks -b C2'$G 0�" mor=TT*roc .4- Vp_�r <br /> Jas repair done under inspect! 14o ere soft samples analyzed? eso TXE PH-G PH-0 b/E08 <br /> Type of failure/discharge atastroFhic tong-term leakage verfi[l ✓ nkiliown II cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> E <br /> h + <br /> oil Samptes Received es IV o I epth to Ground water of/Year verage Annual Precipitation <br /> i s <br /> Dri <br /> -Site Welt(s) es a umber & Type Irr om vb <br /> S c Ir,e S Score 5 Score j <br /> istance to Ue[l(s) from Tank ft; ft; ft C o pts C pts C pts <br /> 0 if 11 0 if 0 if <br /> R rondition R condition R orld i t i on <br /> Site Feature - Leaching Potential Analysis E is =net E is suet E is met <br /> inimum Depth to groundwater from the Sail Sample tfeet)20``16 51 >100 1-100 25-50\1 <br /> IE <br /> Fractures in subsurface (appties to foothitls or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 Kxxxxxx 26-40\2 <br /> a;- <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown 31resent <br /> i <br /> nique site features: Recharge area, coarse soit, nearby wells. At least lore than <br /> xxxx Nona one one <br /> 4� <br /> COLUMN TOTALS>>>TOTAL POINTS ��+ V + <br /> teR esu[ (8 T�OR I � RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> p2(o r7�Z �uZ •OZS 8 T X'I� E B T X E <br /> N•.P -0�(} •��8 '� MAXIHLH ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50i 50 .3 .3 1. 1. HA\3 <br /> Sample Result: ASOLINE 1000il[ 100 10 <br /> AXIKJH ALLOWABLE TPH LEVELS (PPM) <br /> TPH IPSEL 10,000iE 1000 100 <br />` FOOTNOTES: ***If documented soil and/or ground waterc ination is present, do not complete the leaching potential <br /> analysis. (i.e., site is Curren yon UGT Contamination Listi1for soil or ground wa�(dieset). <br /> \1 If depth is > 5 ft. and < 25 ft., sca e 0 points. If depth <�5 ft. "sio not use table. <br /> \2 If precipitation is > 40 inches, sca e 0 points.\3 Levels for BTX&E are not applicable a TPH con Ion o"Fspline 9 <br /> V1. STAFF RECCMHENDATION/CONCLUSION �� I <br /> 1. Are 8TX &• E or TPH Concentrations > Alt able Levels Yes o I�i II <br /> 2. Recomisend Site Closure 1Y <br /> es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE CCMPLETED BY A SUPERVISOR/SENIOR <br /> 1' <br /> -ONCUR W17H STAFF RECC01MENDATIOH FOR CLOSURE ES 0 EFERRED TO SITE MITI,'I CAT10'!'FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> r y <br /> rAME OF <br /> ;VALUATOR Ii <br /> EH 23 80 (UGTWKSHT)\5/90 <br />