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SAN JOAGUIN C0-_-Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL- )1VISION <br /> I' err/ WORKSHEET FOR SITE CLOSURE EVALUATIONATE 3 <br /> AME OF FACILITY P,6 , f (5 EEPS CODE <br /> DRESS (/pVj> � &-4e_ TANK [D # 3 <br /> TANK SIZE /,q 010,9 UEL TYPE fi,-ff <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # - acitity Status Code oc.Soil/GW Cont IYes o <br /> umber of Tanks at facility kge of Tanks(if available) IType of Tank teel kFbrgt I ISngt. Dual <br /> III. TANK HISTORY <br /> Jas Tank testedT es a ailed precision test ? es o If yes, give dates) <br /> Jas a repair made to the tank system? es No f yes, what was repaired? <br /> Jas repair done under inspection? es L No ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term Leakage verfill nown cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es IN01 epth to Ground Water � of/Year �� verage Annual Precipitation <br /> -Site Wells) es o umber 8 Type Irr om b <br /> S Score S Score S core <br /> istance to Welt(s) from Tank ft; ft; ft C 10 pts C pts C pts <br /> 0 if 0 if 0 f <br /> R ondition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E 's met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-5011 <br /> ractures in subsurface (applies to foothills or mountain areas) None . Unknown >resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40L <br /> Ian-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) l b None unknown 2,resent <br /> pique site features: Recharge area, coarse soil, nearby wells. q At least 4ore than <br /> xxxx None / one one <br /> COLUMN TOTALS—TOTAL POINTS Zo + r�J + <br /> Sample Result: (3/T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> 8 T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> ampte Result: SOLINE 1000 100 10 <br /> �Qr / IMUM ALLOWABLE TPH LEVELS (PPM} <br /> (( A" TPN O !6 IESEL 10,000 1 1000 100 <br /> FOOTNOTES: ***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 sail or ground water.) <br /> L If depth is > 5 ft. and < 25 ft., score 0 points. if depth <=5 ft., do not use table. <br /> 12 if precipitation is > 40 inches, score 0 points. <br /> L Levels for 8TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable LevelsYes 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 SUPERVISO SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION fES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />