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SAN JOAQUIN COUNT ''LIC HEALTH SERVICES/ENVIRONMENTAL HEALTH �' <br /> UGE',� :SHEET FOR SITE CLOSURE EVALUATION DATE <br /> hAME OF FACILITY _ �j�7G, EcP. CCC 3 <br /> TANK ID 213?_ <br /> ADDRESS, , <br /> TANK SIZE FUEL TYPE <br /> I . GENERAL SITE HISZORY <br /> Is permit current? Yes No Permit s Facility Status Code � ooc.Soil/GV Cont Yes No <br /> Nurber of Tanks at facility Age of Tanks(if available) ' Type of Tank Steel Fhryl Sngl Dual <br /> LU! <br /> III. TANK HISTORY ` <br /> Was Tank tested? Yes No Failed precision test 7 Yes No If yes, give dite(s) L7 /1f /S; <br /> Was a repair made to the tank system? Yes No kXIf yes, what was repaired? <br /> Was repair done under inspecii on? Yes No Vere 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 /> W. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Vater - G Ref/Year 96, ; Average Annual Precipitation A- 14 10-25 <br /> Cn-Site Well(s) yes No Nurber L Type Irr Dom Pub S Score S Score 5 Score <br /> Distance to Wel((s) 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 /> Minimus Depth to groundwater from the Soil Sample (feet) >100 51-100 25-50\l <br /> Fractures in subsurface (applies to foothills or mountain areas) Nora G Unknown Present <br /> Average A.-Met Precipitation (inches) xxxxxx <10 9 10-25 xxxxxx:t 26-40\2 <br /> Man-Made conduits which increase vertical migration None �! Unkrown Present <br /> of Leachate (i.e., septic systems, water wells, ponds) <br /> At least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxX None <br /> COLUMN TOTALS» 2` - one one <br /> >TOTAL POINTS - =J(y � '5 �// <br /> Sanple Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or More 41 - 48 pts 40 pts or less <br /> �If PJ IJ B T X E a T X E <br /> e C)�'S °Q�"' MAXI MAI ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> A if 0)p �e MAXIMUM ALLOWABLE TPN LEVELS (PPM) DIESEL 10,000 1000 100 <br /> I.a TP <br /> FOOTNOTES: "•lf 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. PP�s (gasoline) or 100 PF's (diesel). <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of iC <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > All able Levels <br /> 2. Recanniend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> COHCJR WITH STAFF RECOMMENDATION FOR CLOSURE YES NOREFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTVKSHT)\5/90 <br />