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SAN JOAOUIN Lt 1'* 1BLIC HEALTH SERVICES/ENVIRONMENTAL HEAL D worSION <br /> t. oGST WORKSHEET FOR SITE CLOSURE EVALUATICN ATE <br /> AME OF FACILITYJdSW11PS E �" <br /> OORESS TANK IO D <br /> 3 9 <br /> IANK SIZE TYPE <br /> 11. GENERAL SITE HISTORY <br /> •w <br /> Is permit current? es o ermit 0 IFacility Status Code 3`/ oc.Soit/GW Cont 1Y <br /> es o <br /> umber of Tanks at facility / Be of Tanks(if available) ype of Tank teel brgl ngl Dual <br /> 19 <br /> III. TANK HISTORY <br /> as Tank tested7 es o vf.iLed precision test 7es o If yes, give date(s) <br /> as a repair made to the tank system? 1Yes No f yes, what was repaired? <br /> Jas repair done under inspection? es I qo ere soil samples analyzed? es a Ig TXE PH-G PH-D FF/EDB <br /> IT ypc of failure/discharge atastrophic long-term leakage verfill known I lo <br /> then: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water O of/Year verage A ual cipitation N, 4 0-25 <br /> Lit <br /> e Well(s) es o umber b Type Ir r om ub <br /> S core S core S core <br /> e to Well(s) from Tank � ft; f r, ft C 0 pts C pts C pts <br /> O if 0 if 0 f <br /> R ondition R condition R onditian <br /> Site Feature - Leaching Potential Analysis E is met I E is met E s met <br /> inimum Depth to groundwater from the Soil Sample <feet) >100 ( 1-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None / Unknown Dresent <br /> %verage Amuat Precipitation (inches) KXXXXX <10 9 10-25 xxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None 61 Unknown resent <br /> ique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS Q <br /> + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 1 - 48 p 40 pts or less <br /> B 1 T X E 8 T X E <br /> MAXIMLIM ALLCWABLE S-T-X-E LEVELS (PPM) 1 50 50 4A\3 <br /> ample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> COTNOTES: ***if documented soil and/or ground water contamination is present, do tete the leaching potential <br /> analysis. (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 BTX3E are not applicable at a TPH Concentra ibn of 10 ppm (gasoline) or 100 esel). <br /> V1. STAFF RECCHMENDATION/CCNCLUSION <br /> 1. Are BTX 3. E or TPH Concentrations > Altowa /Levels Yes I INO <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE CCMPLETED BY A SUPERVISOR/SENIOR <br /> _ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES 0 EFERRED TO SITE MITIGATION FOR EVALUATION fES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> LAME OF <br /> :VALUATCR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />