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SAN JOAQUIN COUN' aLEC HEALTH SERVICES/ENVIRONMENTAL HEALTH- 'ISICN <br /> U 1RKSNEET FOR S[TE CLOSURE EVALUATION (" DATE <br /> AM: OF FACILITY <br /> yr � <br /> D0 RSSS� / 73 /'j <br /> � (�� TANK iD ., 3 ';P9-0 <br /> AHK SIZE R FUEL TYPE <br /> GENERAL SITE HISTORY 'j <br /> :s permit current? Yes No Permit 9 - Facility Status Code Doc.Soi UGV Cont Yes Na <br /> i <br /> IL:[lber of Tanks at facility Age of Tanks(if available) Type�of Tank Steel Fbrgt SngL Dual <br /> TANK !41 STORY <br /> las Tanis tested? Yes N�o Failed precision test ? Yes Ho If yes, give dates)vas a repair made to the system? Yes No if yes, what was repaired? <br /> was repair done under inspection? Yes No were soil samples analyzed? Yes ; NoBTXE TPN-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br /> REMOVAL HISTORY (ATTAC4 INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) _ <br /> SoiL Samples Received Yes No Depth to Ground Vater Ref Year ; <br /> Average Annual Precipitation A= 14 10-25 <br /> i <br /> ion Site WeLI(s) Yes No Nurber & Type Irr Dam Pub <br /> S Score S Score S Score <br /> Distance to WeLL(s) from Tank ft; ft; ft C 10 pts L 9 pts C 5 pts <br /> O if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> I >i0i0 51-100 25-50%1 <br /> SMinim.m Depth to groundwater frau the Soil Sample (feet) <br /> II None Unknown Present <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> Average Annual Precipitation (inches) xxxxxx 410 9 10-25 Itxxxxxx 26-4D\2 <br /> iv <br /> Han-Mace conduits Which increase vertical migration Nave Unknown Present <br /> of Leechate (i.e., septic systems, water wells, ponds) <br /> /, At least More than <br /> (Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx Huse `�f one one <br /> COLUMN TOTALS>>>TOTAL POINTS + <br /> 3 <br /> RANGE OF TOTAL POINTS 49 pts or more is 40 pts or less <br /> Sampte Result: (a T X OR E) <br /> jC 9 T X I; E 8 T]III <br /> XE <br /> MAXIF47M ALLOVAHIE B-T-%-E LEVELS CPPV) 1 50 50 .3 . 1. 1. Nll\3 <br /> GASOLINE 1000 100 10 <br /> Sample Result: <br /> 0-3z 7QtPTPH <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL 10,000 1000 100 <br /> -- <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. a <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 LVA. L�(� � <br /> 1. Are BTX & E or TPH Concentrations > ALtowabte Levels 'lies No <br /> 2. Recommend Site Closure Yes No 'If Yes, Refer to Site Mitigation for Eva!'uation <br /> VIE. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CL4)SURE YES NO REFERRED TO SITE MYTIGATiOH FOR EVALUATION YES NO <br /> DATE REFERRED / / DAIE CLOSURE LETTER MAILED / / <br /> HAME OF <br /> EVALUATCR iE <br /> -H 23 SO (UGnXSHT)\5/90 <br />