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SAN JOAQUIN �/Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA�IVISION <br /> I. QST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> OF FACILITY CUS EPS CODE 2 <br /> SS b� h ANK 10 N <br /> AIHC SIZE UEL TYPE , <br /> II. GENERAL SITE HISTORY 11�Q-S �� <br /> Wrt arn'ent? res o nit N acility Status Code oc.Soit/GW Cant es o <br /> f Tanksat facility, Be of Tanks(if available) ype of Tanis teat broi l wall <br /> 111. TANK HISTORY <br /> Jas Tank testeo es o acted precision test t Ires 0 If yes, give date(:) <br /> as a repair made to the tank systea? yes No f yes, what was repaired? <br /> An repair dons under inspections es 40 re soil samples analytaw es I o I TXE I PH-G PH•D /EDB <br /> ype of facture/discharge tastrophic long-term leakage rfilt rp=l ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> it Samples Received as th to Grou*sd*Water 0 /Year Yv verage Annual Precipitation = 4 0-25 <br /> Site Walla)pas o r i Type rr <br /> S ore S core S core <br /> isto" to Watt(s) from Tank ft; ft; ' ft C 0 Pts C pcs C PCs <br /> 0 f 0 if 0 f <br /> R ondition R andition R ondition <br /> Site Feature • Leaching Potential Analysis E s Met E is met E s met <br /> inimum Depth to grougimater from the Soil Sample (feet) -100 1-100 254011 <br /> ractures in subsurface (applies to foothills or mountain areas) None l unknown Present <br /> Were" Anrlwt Precipitation (inches) MUM <10 9 10-25 Kxxxxxx 26-40.0 <br /> -Made conduits which increase vertical migration <br /> f leachate cf.e., septic systema, water welts, ponds) , Nana Unknown resent- <br /> ique site features: Recharge area, coarse soil, nearby wells. At least re than <br /> None ax One <br /> COLUMN TOTALS>»TOTAL POINTS $* 41 + <br /> to Result: (B TT X OR E) RANGE OF TOTAL POINTS 9 pts or - 48 pts 40 pts or less <br /> �✓ ,w 7` ' r� MAXIMA ALLOYABLE B•T•X-E LEVELS (PPM) 1 SO SO3 1. 1. NAy�.I J.X I <br /> INE 1000100 10 <br /> ALLOWABLE TPH LEVELS (PPM) <br /> TPNIESEL 10,000000 100 <br /> 00TUOTES: '"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 soft or ground water.) <br /> 1} If depth is > S ft. and < 25 ft., score 0 points. If depth <-5 ft., do not use table. <br /> If precipitation is > 40 inches, score 0 points. <br /> y� Levels for BTXLE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (dfeset). <br /> V1. STAFF RECOMMENDATION/CONCLUSION ,. <br /> 1. Are BTX L E or TPH Concentrations > Attoweble Levels Yes o <br /> 2. ltecoeaxnd Site Closure as if Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> W <br /> ITH STAFF RECOMMENDATION FOR CLOSURE ES EFERREO 10 SITE MITIGATION FOR EVALUATION S )40 <br /> ATE CLOSURE LETTER MAILED y <br /> EN 23 80 (UGTWKSNT)V140 le-cl sell ,S <br /> 1 <br />