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SAN JOAQUIN ?-BLIC HEALTH SERVICES/ENVIRONMENTAL N )[VISION <br /> WCRKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> AE OF FACILITY v� 7� SWEEPS CCOE Z� /Ov -7 <br /> ADDRESS 76 �Lt�/ rF- (TANK 10 4 <br /> a <br /> TANK SIZE �- FUEL TYPE W�D <br /> 11. GENERAL SLTE HISTORY <br /> Is permit current? Yes No Permit S - Facility Status Code OaC.SOi I/Gw Cont Yes No <br /> Nufnber of Tanks at facility Age of Tanks(if available) l/a Type of Tank Steel Fbrgl Sngl Dual <br /> i <br /> Ill. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes soI If yes, what was repaired? <br /> Was repair done under iaspection7lYes No Were soil samples analyzed? Yes Na STXE TPH-G TPN-D Pb/EDB <br /> Type of failure/discharge catastrophic ILam-tem Leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FCR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil SampLes Received Yes No Depth to 1-7rnd Water Ref/Year Average A ual Precipitation A= 14 10-25 <br /> On-Site Wells) Yes No Number & Typal lrr Dam Pub <br /> S Scare S Score 5 Score <br /> Distance to Welts) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 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 /> Minim Depth to groundwater from the Soil Sade (feet) Z 7 I >100 151-100 25-50\1 <br /> Fractures in subsurface (applies to foothills x mountain areas) None 17 Unknown Present <br /> Average Annual Precipitation (inches) xxxxxxl <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of Leachate (i.e., septic systems, water wells, ponds) None 1� Unknown Present <br /> Unique site features: Recharge area, coarse wiL, nearby wells. At Least More than <br /> xxxxxx None one we <br /> COLUMN TOTALS>»TOTAL PCIYTS ' + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more s 40 pts or Less <br /> �-,.\o., B T X E B T X E <br /> �'= •0FZ Alk, MAXIMUM ALLOUX3 B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sante Result: GASOLINE 1000 100 10 <br /> rl.D-; 10A#`l MAXIMUM ALLOWABLE :79 LEVELS (PPM) <br /> D.- w/ TPH-6- DIESEL 10,000 1000 100 <br /> FOOTNOTES: —If documented soil and/or ;rand 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 ir:=nes, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF 2ECOMMENDATICN/CONCLUSION � ' � Del <br /> L DrcIICc?R <br /> 1- Are BTX & E or TPH Concentrations > Allowable Levels 'Yes No A <br /> (5.,P^ A S crul��,>Ry e <br /> 2- Recommend Site Closure Yes No � If Yes, Refer Site Nitigat ion far Evaluation .Iz <br /> - sFrP�. ,•� ,Prcdr6�ie <br /> VIE. REVIEW EVALUATION - TO BE COMPLETED BY A SLPSZVISOR/ NIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE:TESI NO REFERRED TO SITE MITIGATION FOR EVALUATIONIYES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />