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SAN JOAQUIN CC ;,f PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL,,, DIVISION p <br />I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE CJ— O — 03 <br />NAME OF FACILITY Tb S le IJ S SWEEPS CODE <br />ADDRESS I �Z� " cv-' + �,_j,� i1 A� CtGJ71j7 _ TANK ID # <br />TANK SIZE 10,190 0 FUEL TYPE �1e�(,Q T <br />II. GENERAL SITE HISTORY <br />*** <br />Is permit current?Yes No Permit # - Facility Status Code Doc.Soil/GW Cont Yes No <br />Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br />III. TANK HISTORY <br />Was Tank tested? Yes Y No Failed precision test ? Yes No x If yes, give date(s) <br />Was a repair made to the tank system? Yes �( No If yes, what was repaired? y.{ V OC <br />Was repair done under inspection? Yes No Were soil samples analyzed? Yes X No BTXE TPH G TPH-D ,( Pb/EDB <br />Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br />iV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR icerwTur. DnTCUTTA1 AIIA— fn <br />Soil Samples Received <br />Yes <br />Yj <br />No <br />Depth to Ground Water <br />10 Ref/Year ST el ; q Gl <br />Average Annual Precipitation <br />NO <br />A= <br />14 <br />10 25 <br />On -Site Well(s) <br />Yes <br />No <br />EVALUATOR <br />E iZ OA <br />Number & Type <br />Irr <br />Dom <br />Pub <br />S <br />C <br />0 <br />R <br />E <br />Score <br />10 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />9 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />5 pts <br />if <br />condition <br />is met <br />Distance to Wells) from Tank <br />ft; ft; ft <br />V. Site Feature - Leaching Potential Analysis <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 />None <br />Gj <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, ponds) <br />None <br />y <br />Unknown <br />Present <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />xxxxxx <br />None <br />9 <br />/ <br />At least <br />one <br />More than <br />one <br />COLUMN TOTALS»>TOTAL POINTS <br />+ <br />13 <br />+ <br />5 <br />= q I <br />Sample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />41 - 48 pts <br />40 pts or less <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />B <br />1 <br />T <br />50 <br />X 50 <br />E <br />50 <br />B <br />.3 <br />T <br />.3 <br />X <br />1. <br />EE <br />NA\3 <br />Sample Result: <br />�O►Lw` TPH <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />GASOLINE <br />1000 <br />100 <br />10 <br />DIESEL <br />10,000 <br />1000 <br />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 />\2 If precipitation is > 40 inches, score 0 points. <br />\3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />... r.� ���..an ll ­ l I—/LV1 LUQ 1VM <br />I. Are nix a t or TPH Concentrations > Allowable Levels *Yes No <br />2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation <br />I. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE <br />YES <br />NO <br />REFERRED TO SITE MITIGATION FOR EVALUATION <br />YES <br />NO <br />DATE REFERRED <br />/ / <br />DATE CLOSURE LETTER MAILED <br />NAME OF <br />EVALUATOR <br />E iZ OA <br />