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SAN JOAQUIN CIX"QTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTw DIVISION DATE S ,� Z _ cy -� WORKSHEET FOR SITE CLOSURE EVALUATION 1 S EEPS CODE t� NAME OF FACILITY I o n } ADDRESS TANK ID # C.� I n TANK SIZE G �Q v FUEL TYPE I ,he g -C ll. GENERAL SITE HISTORY Is permit currents Yes o Permit #�IfT, �,,,,12LIF)11' ility Status Code Doc.Soil/GW Cont Y" N Number of Tanks at facility �- AV n � Type of Tank Steel brgt Sngl Dust III. TANK HISTORY Was Tank tested? Yes o Failed precision test 7 Yes No !f yes, give date(s) Was a repair made to the tank system? Yes No f yes, what was repaired? Was repair done under inspection? Yes No �- Were soil samples analyzed? Yes No BTXE TPH TPH•D Pb/E Type of failure/discharge catastrophic long-term leakage overfill known other: TC ncTA„ eirnllcrT DATA FOR LEACHING POTENTIAL ANALYSIS) !• 8 iY. REMOVAL HISTORT (AIIAI.m �aarv��+�� ^��^ ^•• _•'--------' Soil Samples Received Yes No Depth to Ground Water 'C., Ref/Year �- (� ; Average Annual Precipitation A= 14 10-25 On -Site Wells) Yes No Number & Type Irr Dan Pub S Score S Score S Score Distance to Wells) from Tank P '2�f t; ft; ft C 10 pts C 9 pts C 5 pts 0 if 0 if 0 if R condition R condition R condition V. Site Feature - Leaching Potential Analysis E is met E is met E is met Mini mum Depth to groundwater from the Soil Sample (feet) .— >100 51.100 25-50\1 I� None Unknown Present Fractures in subsurface (applies to foothills or mountain areas) r Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 Man -Made conduits which increase vertical migration , O None -- Unknown —' Present of leachate (i.e., septic systems, water welts, ponds) At least More than Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None C/ one gone COLUMN TOTALS» >TOTAL POINTS 20 t ` 6 { _ "k Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less B T X E B T X E MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 Sample Result: GASOLINE 1000 100 10 MAXIMUM ALLOWABLE TPN LEVELS (PPM) 100 TPN DIESEL 10,000 1000 .....I ems. rhe 1==rhino totential FOOTNOTES: if documented soil and/or ground waterr=�_•••. -- -- --- --- analysis. (i.e., site is currently on LOT Contamination List for soil or ground water.) \1 if depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. \2 If precipitation is > 40 inches, score 0 points. ppm (diesel). \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 V1. STAFF RECOMMENDATION/CONCLUSION 1. Are BTX & E or TPH Contentrationn > Allowable Levels •Yes No 2. Recommend Site Closure Yes No =If Yes, Refer to Site Mitigation for Evaluation VII. REVIEW EVALUATION • TO BE COMPLETED BY A SUPERVISOR/SENIOR CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES INOF REFERRED TO SITE MITIGATION FOR EVALUATION YES NO DATE REFERRED / / DATE CLOSURE LETTER MAILED NAME OF EVALUATOR EM 23 80 (UGTWKSHT)\5/90 FOOTNOTES: if documented soil and/or ground waterr=�_•••. -- -- --- --- analysis. (i.e., site is currently on LOT Contamination List for soil or ground water.) \1 if depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. \2 If precipitation is > 40 inches, score 0 points. ppm (diesel). \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 V1. STAFF RECOMMENDATION/CONCLUSION 1. Are BTX & E or TPH Contentrationn > Allowable Levels •Yes No 2. Recommend Site Closure Yes No =If Yes, Refer to Site Mitigation for Evaluation VII. REVIEW EVALUATION • TO BE COMPLETED BY A SUPERVISOR/SENIOR CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES INOF REFERRED TO SITE MITIGATION FOR EVALUATION YES NO DATE REFERRED / / DATE CLOSURE LETTER MAILED NAME OF EVALUATOR EM 23 80 (UGTWKSHT)\5/90