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It. GENERAL SITE HISTORY <br />III. TANK HISTORY <br />SAN JOACUIN CELIC HEALTH SERVICES/ENVIRONMENTAL HEALT ISION <br />U . WORKSHEET FOR SITE CLOSURE EVALUATICNI <br />N <br />Jas Tank tested? <br />es <br />I V�o <br />epth to Ground Vater <br />IF ailed precision test ?es <br />of/Year <br />/ / =ATE <br />o <br />/ <br />If yes, give date(s) <br />/ <br />as a repair made to the tank system? es No f yes, what was repaired? <br />Les S <br />:ws repair done under inspection? es q0 <br />ere soil samples analyzed? 1Yes <br />S core <br />o <br />core S <br />KyXE <br />f ITPH.G <br />PH -0 <br />b/EDB <br />ype of failure/discharge <br />0 if <br />atastrophiclong-term <br />leakage <br />f <br />verfitt <br />R <br />known <br />ondition <br />then: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />oil Samples Received es <br />ES <br />o <br />epth to Ground Vater <br />of/Year <br />/ / =ATE <br />verage Arnuat Precipitation <br />/ <br />LAME CF <br />:VALUATOR <br />-Site Welts)es o wanber L Type irr cm ub <br />S core <br />S <br />core S <br />core <br />istance to Well(s) from Tank ft; ft; , ft C 10 pts <br />C <br />9 pts C <br />pts <br />0 if <br />0 <br />if 0 <br />f <br />R condition <br />R <br />condition R <br />ondition <br />1. Site Feature - Leaching Potential Analysis E is met <br />E <br />is met E <br />s met <br />inimum Depth to groundwater from the Solt Saaple <feet) >100 <br />1-100 <br />25-50\1 <br />ractures in subsurface (applies to foothills or mountain areas) Nate <br />Unknown <br />21resent <br />%verage Amuat Precipitation (inches) xxxxxx <10 <br />9 <br />10-25 xxxxxxx <br />26.40\2 <br />an -Made conduits which increase vertical migration <br />f leachate (i.e., septic systems, water wells, ponds) None <br />Unknown <br />resent <br />niGue site features: Recharge area, coarse soil, nearby wells. <br />At least <br />are than <br />xxxx Notre <br />one <br />one <br />COLUMN TOTALS»>TOTAL POINTS + <br />+ <br />Sample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS 9 pts or more <br />41 - 48 pts 40 pts or less <br />B <br />T <br />X <br />E <br />S T <br />MAXIMLM ALLOWABLE B -T -X -E LEVELS (PPM)1 <br />5050503 <br />1 <br />.3 <br />7XE <br />. NA\3 <br />Sample Result: <br />ASOLINE 1000 <br />100 10 <br />AXIMUM ALLOWABLE TPH LEVELS (PPM) <br />TPH <br />IESEL 10,000 <br />1000 100 <br />FOOTNOTES: °f°If documented soil and/or ground water contamination is present, do not complete the teaching 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 BTXBE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECCMMENOATtON/CCNCLUSION <br />1. Are BTX & E or TPH Concentrations �> A—llowable Levels Yes 01 1 <br />2. Recommend Site Closure es I No 1 tf Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION( - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE <br />ES <br />0 I EFERRED TO SITE HITIGATICH FOR EVALUATION ES <br />0 <br />ATE REFERRED <br />/ / =ATE <br />CLOSURE LETTER MAlIED <br />/ <br />LAME CF <br />:VALUATOR <br />EH 23 80 (UGTVKSHT)\5/90 <br />