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SAN JOAOUIN �Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE "DIVISION <br /> 1_ ST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> / E <br /> PS CODE X37 <br /> nME CF FACILITY 1e,. /ur, +c� L�oG S� S - <br /> ANK ID <br /> DDRE SS 2 C,0 >Y 3 9 /Y3 - o <br /> [AHK SIZE /Gj000yC UEL TYPE G�l���crC7 <br /> 11. GENERAL SITE HISTORY <br /> ss <br /> Is permit current? es o ermit # - acility Status Code C7/ oc.Soil/Gw Cont es o <br /> umber of Tanks at facility � ge of Tanks(if available) ype of Tank tee l brgl ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested7 Fe7s o ailed precision test ? es o If yes, give dates) <br /> as a repair made to the tank system? Yes No f yes, what was repaired? <br /> Jas repair done under inspection7 es No ere soil samples analyzed? iYes o TXE IT <br /> PH-G I PH-D b/EDB <br /> ype of faiEureldischarge atastrophic long-term leakage verfill nown Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPEC N REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water of/Tear s �� verage Arnual Precipitation 4 0-25 <br /> -Site WGII(s) es o umber b Type I Irr I om I b <br /> S Score S Score S 3core <br /> istance to Well(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 f <br /> R onditicn R- condition R ondition <br /> 61. Site Feature - Leaching Potential Analysis _ E is met E is met E s met <br /> inimm Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown DIresent <br /> ique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> Kxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + Z + o 7 <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS E <br /> pts or more 41 - 48 pts 40 pts or less <br /> B T X E B JT I X I E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: ASOLINE 1000 100 10,•.. <br /> p IMUM ALLOWABLE TPH LEVELS (PPM) <br /> 1p . TPH IESEL 10,000 1000 100 <br /> OOTHOTES: "`If documented soil and/or ground water contamination is present, do not complete the leac 'ng potentia <br /> anatysis. (i.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 /> \3 Levels for BTXEE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> :I. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure 1Y <br /> 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 YES 0 EFERRED TO SITE MITIGATION FOR EVALUATION YES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED / ! <br /> TAME OF <br /> :VALUATOR <br /> EH 23 80 (UGTUKSHT)\5/90 <br />