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SAN JOACUIN\ ATY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEIDIVISION <br /> !. QST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY I ECORD ID <br /> 1 <br /> OORESS ANK ID <br /> ANK SIZE I ��/�X3 UEL TYPE <br /> II. GENERAL SITE HISTORY 1 <br /> lis permit current? es o ermit lFacitity Status Code oc.SoiL/GW Cont es o <br /> i <br /> umber of Tanks at facility �ge of Tank(if available) Q,l =Type of Tank feel I Fbrgl ngl Dual IV <br /> it,. TANK HISTORY <br /> Las Tank tested? �tes I o gaited precision test ? es o I If yes, give date(s) <br /> 'Was a repair made to the tank system?Fs f No �f yes, what was repaired? <br /> I:as repair done under inspection? �es 1. �40 Jere soil samples analyzed? es o TXE PH-G PH-0 b/EDB <br /> ype of failure/discharge atastrophicI long-term leakage verfit[ I kga�nl ther- <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> �SoiL Samples Received fes o' epth to Ground hater 10 1ef/YearlS ;� verage Annual Precipitation = h4 h0-25 <br /> n-Site Well(s) es o pumber 8 hype IrrI Dcm( pub <br /> PC- <br /> S care S core S core <br /> istance to Wetl(s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 f 0 if 0 f <br /> R audition R ondition R ondition <br /> !:. Site Feature - Leaching Potential Analysis E s mets met -t s met <br /> Minimum Depth to groundwater from the Soil Sample (feet) $FY I >100 f 1-100 ( D I25-50\1 <br /> Fractures in subsur-face (applies to footIiils or mountain areas) None I Unknown I present <br /> Pverage Annual Precipitation (inches) KXXXXX I <10 I 9 f 10-25 xxx 26-40L <br /> tan-Made conduits which increase vertical migration I I <br /> bf leachate (i.e., septic systems, water wells, ponds) None , Unknown resent <br /> Onique site features: Recharge area, =arse soil, or wells. q At Least are than <br /> I [M�cipal=>2000 ft; domestic=>500 ft; irr/agricultural=oresentl x ! None I I one one <br /> ICOLUMN TOTALS»»TOTAL POINTS + I I + I O <br /> Samole Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more I 41 - 48 pts 40 p(ts--*= ess <br /> _ Cos <br /> .r 10 <br /> 006 N0o1Yo PPM <br /> 45—. tx,�— , p y$pPA1 B 7 X E B i X E <br /> Q e+m n� MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\ <br /> i <br /> ample Resu 1t AD 1��f0�1' OLINE 1000 <br /> g� 100 10 <br /> IMUM ALLOWABLE TPH LEVELS (PAN) <br /> ���TPH[&� <br /> IE 10,000 1000 100 <br /> r`�COTNOTES. —If documented soil and/or ground water contamination is present, do not complete the leaching potentiat <br /> ianalysis. 0.e-, site is currently on UGT Contamination List for soil 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 /> 13 Levels for BTX&E are not applicable at a TPH concentration of 10 Fpm (gasoline) or 100 ppm (diesel). <br /> Vi. STAFF RECOMMENDATION/CONCLUSION <br /> I. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o IJ If Yes, Refer to Site Mitigation for Evaluation <br /> VIi. REVIEW EVALUATION - TO BE COMPLETED fY A SUPERVISOR/LEAD SENIOR <br /> -ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES EFERRED 70 SITE MITIGATION FOR EVALUATION ES 001 <br /> ATE REFERRED I / / '� i bATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />