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SAN .IOACUIN C _ELIC HEALTH SERVICES/ENVIRONMENTAL HEAL ;ION <br /> C WRKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AGILITY EPS CODE p'J ell <br /> ANK IDX <br /> /SIZE �C/�G7 UEL TYPE <br /> i <br /> GENERAL SITE HISTORY <br /> ;Is permit current7 es o ermit X - acitity Status Code �� oc.Soil/GW Cont es o <br /> 'ur,ber of Tanks at facility ge of Tanks(if available) N ype of Tank teel Fbrgl I rgL Dual <br /> :. TANK HISTORY <br /> =as Tank tested7 es o ailed precision test 1 es o If yes, give dates) <br /> is a repair made to the tank system? as No yes, what was repaired? <br /> ins repair done under inspection? as F go ere soil samples anatyzed7 es o f PH-G H-0 I b/EDB <br /> Vo of failure/discharge atastrophic tang-term leakage verfill noun ther: <br /> REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> :oil Samples Receivedes o epth to Ground Vater of/Year -�(� ; verage Arcual Precipitation a 4 0-25 <br /> `.:n-Site Well(s) es o I umber 1. Type I Irr I ub <br /> S coreS core S core <br /> ristance to Wetl(s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 f 0 if 0 f <br /> R onditim R ondition R ondition <br /> Site Feature - Leaching Potential Analysis E 's met E is met E 's met <br /> 'o imam Depth to groundwater from the Soft Sample (feet) >100 1-100 O 25-50\1 <br /> <ctures in subsurface (applies to foothills or mountain areas) None Unknown Dresent <br /> ^rage Amuat Precipitation (inches) ou=x <10 9 10-25 xxxxxxx 26-40\2 <br /> n-Rade conduits which increase vertical migration Ci <br /> .i leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> '.lnic?ue site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> %x None / one one <br /> COLUMN TOTALS>>>TOTAL POINTS —3 L <br /> am le Result: (B T X OR E�eh RANGE OF TOTAL POINTS 9 pts or Aare 41 - 48 pts 40 pts or less <br /> T X E B T X E <br /> �X n>oo o MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. HA\3 <br /> �Sampte Result: PP f' ASOLINE 1000 100 10 <br /> ' IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> -GOINOTES: "•If doctmented soil and/or ground water contamination is present, do not complete the Leach in9 potential <br /> analysis. (i.e., site is currently on LOT 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 BTXBE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> :. STAFF RECOWSUDATION/CCWICLUSION <br /> 1. Are BTX $ E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Reccmmerd Site Closure es o If Yes, Refer to Site Mitigation for Evatuation <br /> :I. REVIEW EVALUATION - TO BE COMPLETED 8Y A SUPERVISOR/SENIOR <br /> -,NCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES ilEFERRED TO SITE MITIGATION FOR EVALUATION ES <br /> i)d;E REFERRED / ' / ATE CLOSURE LETTER MAILED <br /> LAME OF <br /> :VALUATOR <br /> CH 23 80 (UGTWKSHT)\5/90 <br />