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SAN JOACUIN 'USLLC HEALTH SERVICES/ENVIRONMENTAL HEA# SION ATE <br /> 1 N#T10RKSHEET FOR SITE CLOSURE EVALUATIOH <br /> " rOORESS <br /> =. - <br /> 11. <br /> A EPS LOGE /Slj 3 <br /> S 7�� ANKTD ff 39 - X5"0 3 GENERAL SITE HISTORY �* <br /> is permit current? es v ermit N p /sII acility Status Codeafg <br /> G4 Cont es o <br /> *jmber of Tanks at facility ge of Tanks(if available) ype of Tankl ngl Dual <br /> ill. TANK HISTORY <br /> as Tank tested? es o ailed precision test 7 es v itf yes, give date(s) <br /> as a repair made to the tank system? es No 11f yes, what was repaired? <br /> as repair done torder inspection? es go ere soil sampLes analyzed? es o TXE PN-G PH D b/EDB G <br /> is I <br /> ype of failure/discharge atastrophic long-term Leakage verfiEL known cher: <br /> TV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es v epth to Ground dater /G+ of/Year verage Annual Precipitation = 4 0-25 <br /> Site wett(s) es r <br /> o umber b Type I )am ub <br /> 5 torr S core S core <br /> istance to WeLL(s) from Tank ft; ft; ft C 10 pts C 9 pts C i pts <br /> 0 if 0 If D f <br /> R ondition R condition R ondition <br /> J. Site Feature - Leaching Potential Analysis E s met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50\1 ! <br /> ractures in subsurface (applies to foothilts or mountain areas) None Unknown 31resent <br /> -rage Annual Precipitation (inches) xxxx <10 9 10-25 KXAXxxx 26.40\2 <br /> -Made conduits which increase vertical migration i <br /> f Leachate (i.e., septic systems, water wells, ponds) None Unknown Dresent <br /> ique site features: Recharge area, coarse salt, nearby welts. At Least 4ore than <br /> Kxxxxx None one one <br /> COLUMIi TOTALS?»TOTAL POINTS * ` <br /> ampte Result: (B I X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> B T X E 8 T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> ample Resutt: /�yyJ ] <br /> GASOLINE 1000 100 10 <br /> /� I Il1l1F! ALLOWABLE TPH LEVELS (PFM) <br /> 4! fo TPN—& 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the teaching potential <br /> anatysis. (l.e., site is currently on UGT Contamination List for snit or ground water.) <br /> \1 if depth is > 5 ft- and A 25 ft., score 0 points. If depth 4=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levets for BTXEE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Atlowabt Levels Yes o <br /> 2. Recommend Site Ctosure Ires 1 111o tf Yes, Refer to Site Mitigation For Evaluation <br /> Vii. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> 'VCUR WITH STAFF RECOMMENDATION ;FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> LAME OF <br /> :VALUATOR <br /> EN 23 80 (UGTWKSHT)\5/90 <br />