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1. SAN JOAQL1j 'TY PUBLIC HEALTH — _---_ <br /> ..ST WORKSHEc7 FOR SITES [C5�/E E[R4ALWTIwI.r :d DIVISION <br /> INANE OF FACILITY I DATE1 <br /> / Sa.+I r7al�fj �•Jil.-/ SWEEPS CODE 7 <br /> 1ADORESSI �/ A (-71 zJ <br /> (TANK SIZE( �/� (FUEL TYPE1 T I�� (TANK fD a` 3.7 X713 Q� <br /> "! d i oSE�. I <br /> [[. GENERAL SITE HISTORY <br /> Ifs permit current? Yes INo1 1Pamit 3I <br /> Facility Status Code 10oc.Sail/GW CantlYelI Npl <br /> Number of Tanks at facility (Age of ianks(if availad e) IT <br /> :ft. TANK HISTORY YPe of TanklSteel 1Fbrgt 1Sngl pus <br /> {I <br /> -Was sank tested?1Yes INoI Failed precision cat <br /> Yea, INo If Yes, give date(s)I <br /> Was a repair made ca the tank system7lYes1 I <br /> No If Yes, what was reps,red?) . <br /> (Was repair done raider inspec2pon71Yes <br /> Nol Were soil Sa Loa anaLYZed7 Yell Nal JG 61 IiPH-G1 ITP"-D 1Pb/EDB <br /> IType of failure/dischargeI Icatastropnicl llang-tem leakage) )overfill) un' <br /> IV. REMOVAL HISTORY k2101R1 orher: <br /> (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes INoI (Depth to Ground Water)-Vol Ref/Year <br /> On-Site Wetl(s)IYesI Igo I I 43 Average Annual Precipitation A=114 110-25 <br /> Number 3 Type 11rr Dam IPvo1 <br /> Distance CO We L(s) from Tankl S Scare S Score <br /> ri• ft' f- C 10 pts C y S Score <br /> Pis C <br /> 0 if 5 pis <br /> R condition <br /> jV. Site Feature - Leaching Potential Analysis O if 0 if <br /> R condition R condition <br /> E i5 .met E is met c <br /> ':Minimuo Depih to 9rourdwa2er from the Soil Sample (fee: � is encs I <br /> >100 �l I51-100 I I ZS-50\1 <br /> .'Fractures in subsurface (applies to foorhiLLs or mountain areas) <br /> i <br /> None1 I Unknown I C (Present <br /> ,Average annual Precipi taxipn (inches) <br /> lxxxxxxl <10 I 9 110 -25 ISI 26-40\2 <br /> 'Man-Made conduits which increase vertical migration <br /> laf leachate (i.e., septic systems, water wells. ponds) I I <br /> Mane I I Unknown I j (Present <br /> ;Unique site features: Recharge area, coarse sail, nearby we{ls. III <br /> r:l I At least) More than <br /> >CpppR .Vane I one one <br /> COLUMN 7OTALS>>>TOTAL POINTS <br /> ISampte Resin)2: 13 7 X OR E) RANGE OF TOTAL POINTS 49 pts or Imre I 41 - 48 pts 40 pts or less <br /> MAXIMUM ALLOWABLE 3-7-X-= LEVELS (PPM) 11 50I SOI 50 I .3 I.3 11.I L I NA\3 <br /> Sample Result:.I GASOLINE 1000 1 100 I 10 MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH --� DIESEL 10,000 I 1000 1 I 100 <br /> FOOTNOTES: " If documented soil and/or ground water contamination is present, do not complete the Leeching potential <br /> amlYsis. (i.e., site is currently en UGT Contamination List for soil. or grand water.) <br /> \i !f depth is > 5 ft. and < 2.5 ft., score 0 points. If depth C-5 ft., do not use cable. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for 3TX&E are not applicable at a TPH concentration of 10 ppo (gasctine) <br /> or 100 ppm (dieseU. <br /> f. STAFF RECOMMENDATION/CONCLUSIGN <br /> 1. Are 3TX & E or TPH Concentrations > Allowable Levels •Yell INo1 <br /> 2. Recannend Site Closure <br /> Yes No �Tf Yes, Refer to Site Mitigatim for Evaluation <br /> I. REVIEW EVALUATION - TO 3E COMPLETED 3f A SUPERVISOR SENIOR <br /> CONCUR WITH STAFF RECCMMEHOATION FOR CLOSUREIYES' N01 IREFERR® i0 SITE MITIGATION FOR EVALUATIONIYESI NOI <br /> DATE REFERREOI / 7 / (DATE CLOSURE ii NAILED( <br /> NAME OF <br /> EVALUATOR( <br /> EH 23 80 (UGTWKSHT)\5/ <br />