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NAME OF FACILITY <br />ADDRESS <br />TANK SIZE 4'f,00J <br />oop <br />II. GENERAL S T4CO X1� <br />SAN JOAQUIN COW7Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL <br />W&LT WORKSHEET FOR SITE CLOSURE EVALUATION <br />s Uses >„ C <br />7 <br />DS9 s 1 <br />FUEL TYPEI <br />IVI SIGN C <br />DATE Z �_ / 3 <br />SWEEPS CODE C/�y <br />TANK ID @ 3'7 CMZ _ rJ/ OL 153 <br />ILG� �yi/ 5 <br />++r <br />permit current? Yes a Permit Y Ll Facility Status Code Doc. Soil/GW Cont Yes No <br />bar of Tanks at facility Aga of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br />Was Tank tested? <br />Yeso <br />190 <br />No <br />.Depth <br />Failed precision test 7 <br />Yes <br />Ref/Year <br />No <br />If <br />yes, give date(s) <br />Was a repair made to the tank system? <br />Yes <br />No <br />if yes, what was repaired? <br />I JNUber <br />Was repair done under inspection? <br />YesNo <br />Irr <br />Dom <br />Were soil samples analyzed? <br />Yes <br />No <br />BTXE <br />TPH-G <br />TPH-O <br />Pb/EDB <br />Type of failure/discharge <br />Catastrophic <br />long-term Leakage <br />overfill <br />unknown <br />Score <br />10 pts <br />if <br />condition <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil SanpLes Received <br />Yes <br />190 <br />No <br />.Depth <br />to Ground water <br />S <br />Ref/Year <br />&-6 ; <br />Average Annual Precipitation <br />A- <br />14 <br />10-25 <br />On -Site WeLL(s) <br />Yes <br />No <br />I JNUber <br />i Type <br />Irr <br />Dom <br />Pub <br />S <br />C <br />0 <br />R <br />Score <br />10 pts <br />if <br />condition <br />S <br />C <br />0 <br />R <br />Score <br />9 pts <br />if <br />condition <br />S <br />C <br />0 <br />R <br />Score <br />5 pts <br />if <br />condition <br />Distance to WeIL(s) from Tank <br />ft; ft; ft <br />V. Site Feature - Leaching Potential Analysis <br />E <br />is met <br />E <br />is met <br />E <br />is met <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />51-100 <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />�U <br />None <br />Unknown <br />Present <br />Average Annual Precipitation (inches) <br />xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />of Leachate (i.e., septic systems, water wells, pords) <br />/(� <br />None <br />Unknaat <br />Present <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />At least <br />More than <br />xzxxxx <br />None <br />one <br />one <br />COLUMN TOTALS» ,TOTAL POINTS <br />--) / <br />♦ <br />V <br />40 pts or less <br />Sample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />41 - 48 pts <br />6d. ( of �( _,00 r1�m <br />B <br />T <br />XE <br />B <br />T <br />% E <br />MAXIMIRI ALLOWABLE B -T -X -E LEVELS (PPM) <br />1 <br />50 <br />50 <br />50 <br />.3 <br />.3 <br />1. 1. <br />NA\3 <br />Semple Result: <br />GASOLINE <br />1000 <br />100 <br />10 <br />MAXIMUM ALLOWABLE TPR LEVELS (PPM) <br />10,000 <br />1000 <br />100 <br />TPH <br />DIESEL <br />FOOTNOTES: ***If documented soil and/or grand 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 />\2 If precipitation is > 40 inches, score 0 points. <br />\3 Levels for STX8E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOMDLENDATION/CONCLUSION *Yes N U�Ln� ti9 <br />1. Are BTX 3 E or TPH Concentration > Allowable Levels ( — <br />2. Recommend Site Closure Yes No •If 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 />YES 6 i <br />190 <br />REFERRED TO SITE MITIGATION FOR EVALUATION <br />YES <br />NO I J -+- <br />DAIS <br />DATE REFERRED / / <br />DATE CLOSURE LETTER MAILED <br />NAME OF <br />EVALUATOR <br />:n V oU LUGIws5Hr)\�/yu <br />