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SAN JOAOUIN Cd 'UBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL, LSl0N <br /> I• '.IORKSHEET FOR SITE CLOSURE EVALUATION ATE i7_1 <br /> nME OF :FACILITYEEPS CODE <br /> ADRESS ^ _ <br /> CU TANK <br /> U�I�Kf ANK - <br /> IhNK SIZE UEl TYPE �iCsel <br /> 11. GENERAL SITE HISTORY <br /> Is permit currentl es o ermit /t IF <br /> acility Status Code ae.Sait/Gu Can es o <br /> �. r.~ <br /> tinber of Tanks at facility Be of Tanks(if avaitabte) r' ype of Tank teel Fbrgl ngi Duai <br /> it 1. TANK HISTORY " <br /> ms Tank tested? es. o ailed precision test ? es o If yes, give date(s) <br /> Jas a repair made'to the tank system? es No f yes, what was repaired? <br /> Jas repair done under inspectfon7. es o ere soil samptes analyzed? es o i TXE ' PH-G PH-D b/508 <br /> ype of failure/discharge atastrophic Long-term leakage verfitt nknown ther':\ <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS). l <br /> oil Samples Received Ifes IV 14-1 IJepth to Ground Water of/Year•y ;&6 verage Annual Precipitation 4 0-25 <br /> -Site Weli(s) es o umber 8 Type Irr )cm ub' <br /> 5 Score S Score S' care' <br /> istance to Welt(s) from Tank ft; ft; ft fi 10 pts C 9 pts r C pts <br /> 0 if 0 if 0 f <br /> R andition R condition R w o6idTtion <br /> u. Site Feature- Leaching Potential Analysis E is met E is met E s met <br /> inimum,Depth to groundwater from the SoiL Sampte (feet) 20 -13`c >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 t 9 10-25 KXXXXXx 26-40\2 <br /> an-Made conduits which •increase vertical migration - <br /> f Leachate (i.e., septic systems, water wells, ponds) None Unknownresent <br /> 'pique site :features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxx None .one one <br /> m COLUMN TOTALS»>TOTAL POINTS + + b , 3 <br /> Vie Result! (B T X OR E) w. RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40,pts.or Less- , <br /> 03� 5� �IS �Zi B T % E e T X � E- . <br /> •f <br /> DOS(, .015 N-0 MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 . .3 T. .1. NA\3" <br /> ample Result: ry') ASOL I14E 1000 100 .10 <br /> AXIMUFI ALLOWABLE TPH LEVELS (PPM), <br /> y TPH IESEL 10,000 1000 100 <br /> OOIHOTES: ***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 soit 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 BTXdE are nov applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> '11. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX E or TPH Concentrations > All able Levels Yes o <br /> 2. Recommerd Site Closure es o If Yes, Refer to Site Mitigation for Evaluation ' ° <br /> VII. REVIEW EVALUATION TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 6 EFERRED TO SITE MITIGATION FOR'EVALUATTON ES V 0 ! <br /> ATE REFERRED / / G� ATE CLOSURE LETTER MAILED <br /> �IQ3 80'(UGTWKSHT)\5/90 <br />