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f SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL`THDIVISION <br /> !- US, WRKSHET FOR SITE CLCSURE EVALUATION ATE I <br /> I <br /> I HANE OF FACILITY -t'-OG CCRD ID <br /> t <br /> PORESS I 51C> ANKID - -G <br /> hANK SIZE � /'t IFI7EL TT I D j ,I u 5 <br /> II. GENERAL SITE HISTORY <br /> s permit current? �.Sa ermit - acility Status Code ,' 9- oc.SoiL/GW Cont e-s I o <br /> Nu-toe.^ of Tanks at facility �ge of Tank(if available) IType of Tank teel <br /> IISngi Dual <br /> iii. TANK HISTORY <br /> L'as Tank tested? esc ailed precision test ? Iles �0 ( If yes, give date(s)1 <br /> t:as a repair made to the tank system? es I No f yes, what was repaireat <br /> Was repair done under inspection? Iles I Ivo ere so i samoies analyzed?Wes �Jo I TXE I H-G I PH-0 i b/08 <br /> Type of failure/discharge �atastraphie I long-tens leakage IOverfitl known I ther: <br /> ?V. REEMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soi! Samples Received les TOT �e th to Ground dater b Itef/Tear (average Annual Precipitation I1= 114 110-25 <br /> On-Site Welt(s) (Yes I Fo I dumber b Type( I rr I Pcm I pub I <br /> S core S Score S core <br /> aislance to Well(s) from Tank I ft; ft; ft C 0 pts C 9 pts C pts <br /> 0 c 0 if 0 f <br /> R onditicn R ition R ondition <br /> N. Site Feature - Leaching Potential Analysis E s met E is met E rs met <br /> mini.::--n Depth to groundwater from the Soil Sample (feet)3 o - ( >100 I 1-100 ( © 125-50\1 <br /> Fractures in subsurace (applies to foothills or mountain areas) D ( None ( I Unknown I present <br /> Average Annual Precipitation (inc-'hes) ( <10 I 9 ( 10-25 perxx:ooc ( 26-40\2 <br /> Man-made conduits which increase vertical aigration / <br /> 64 leachate (i.e., septic systems, water wells, ponds) !a None ` ( Unknown I bresent <br /> i.inicue site features: Recharge area, coarse soil, or weds. At Least are than <br /> i rM=c;pa1=>2000 ft; danestic=>500 ft; irr/agricultural=present] xxxx= ' None I � � onel � one <br /> CCLLMN TOTALS»>TOTAL POINTS g ! ` �3? <br /> le Result: 8 T X ORE RANGE OF TOTAL POINTS 9 s or more 41 - 48 is 4O <br /> Same < ) I ? <br /> 1/fA- HlI ND <br /> T �i$ =Fi.;G�SO�Rm, 8 T I X E I B I T IX I E <br /> h' MAXIMUM ALLOWABLE 8-T-X-E LEVELS (PPM) 1 50 50 50 .3 3 1. 1. NA\3 <br /> amole Result: CLINE 1000 lea i 10 <br /> IL'aL I O?p IMUM ALLOWABLE TPH LEVELS (PPM) <br /> Is <br /> 10,000 I 1000 100 <br /> FCOTHOTES: —if docmented soil and/or ground water contamination is present, do not complete the lea ing potential <br /> analysis. (i.e., site is currently an UGT Contamination List for soil or ground wale <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 STXEE are not applicable at a TPH concentration of 10 p,�pmm (g-,,+asolinje)�or 100 ppmL(di�e�saet)- '-b <br /> vi. STAFF RECCMMENDATIOH/CCNCLUSION �LL� ! #TGt-- `Yb,I A, -n? <br /> Are 8TX b E or TPH Concentrations > Allowable Levels es o S N <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> I. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> ^NCJR WITH STAFF RECOMMENDATION FOR CLOSURE AYES Ivo EFERRED TO SITE MITIGATION FOR EVALUATION kEsi �a I <br /> ATE REFERRED I / / bA.. CLOSURE LETTER MAILED <br /> t <br /> At'S CF <br /> `:AL'JATOR <br /> _? 23 80 (UGTWKSHT)\5/94 <br />