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SAN JOAQUIN IRTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAR IVISION <br /> [. UST WORKSHEET FOR SITE CLOSURE EVALUATION DATE 1 40 <br /> AHE OF FACILITY I r ECORD ID <br /> DRESS ( 7/ ANK ID "131 <br /> - <br /> ANK SIZE ` AL TYPE <br /> [I. GE14ERAL SITE HISTORY <br /> Is permit current? es o ermit - acility Status Code cc.SoiL/GW Cant es o <br /> Nurioer of Tanks at facility age of Tank(if available) �fype of Tank teel Fbrgl ngl Dual <br /> iii. TANK HISTORY <br /> was Tank tested? es o ailed precision test ? es o ! If yes, give date(s) <br /> �.as a repair made to the tank system? es I No 11f yes, what was repaired? <br /> 'Was repair done under inspection? �ies � �lo ere soil samples analyzed? es o TXE PH-GI IT <br /> PH-0 �Pb/EDB <br /> Ivpe of failure/discharge atastrophic ) long-term leakage verfill own they: <br /> :V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received fifes o depth to Ground Water of/Year erage Annual Precipitation �i= 4 0-25 <br /> pn-Site WeLL(s) (Yes ( o umber & Type <br /> Ir <br /> pan <br /> 5 core S core S core <br /> istance to We(L(s) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 0 if 0 f <br /> R ondition R condition R ondition <br /> H. Site =eature - Leaching Potential Analysis E is met E is met E s met <br /> Minimum Depth to groundwater from the Sail Sample (feet) I >100 I �1-100 I 25-50N1 <br /> �rac_ures in subsurface (applies to foothills or mountain areas) None Unknown I resent <br /> verage Annual Precipitation (inches) =xxxx ( <10 I 9 10-25 xxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of Leachate (i.e., septic systems, water wells, ponds) None I Unknown resent <br /> Unicue site features: Recharge area, coarse soil, or wells. I At least lore than <br /> r <br /> [MLcipal=>2000 ft; domestic-»00 ft; irr/agricut tura l=present] None one I one <br /> COLUMN TOTALS>>TOTAL POINTS + + <br /> Sample Re ult: (8 T X OR E) RANGE OF TOTAL POINTS 9 pts or more ( 41 - 48 pts i 40 pts or Less <br /> ll IUDAIDB T X 'c 8 T X E <br /> [ a MAXIMUM ALLOWABLE R-T-X-E LEVELS CPPM) 1 50 50 50 .3 .3 1. 1 1. NA_3, <br /> Samote Result: OLINE 1000 100 10 <br /> -- W IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: *" If documented soil and/or ground water contamination is present, do not complete 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 /> L If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> Vi. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> CNCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES EFERRED TO SITE MITIGATION FOR EVALUATION ES NO <br /> ATE REFERRED, I / / BATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />