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SAN JOAQUIN COON' %IC HEALTH SERVICES/ENVIRONMENTAL HEALTH ZION <br /> r, UG'***�(SHEET FOR SITE CLOSURE EVALUATION ti� DATE S �� <br /> NAM: Of FACILITY SWEEPS CODE r%1 4 <br /> ILADORESSI - 31 " 3 A TANK 10 4 _Q <br /> �LTANK SIZE FUEL TYPE I C,Lq n�'''AVM' ' rp <br /> I1. GENERAL SITE HISTORY U Q U —�'-" •.e <br /> Is permit current? Yes No Perm 0 - FacilityStatus Code Doc"Soil/GW Con[ Yes No <br /> Number of Tanks at facility Age of Tanks(if available) IType of Tank Steel Fbrgl sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 Yes No If yes, give dates) <br /> Was a repair made to the tank system Yes No if yes, what was repaired? <br /> Was repair done under impectiw? Yes No Were soil samples analyzed? Yes 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 LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth Co Ground Vater Ref/Year Average Annual Precipitation A• 14 10-25 <br /> On-Site Wells) Yes No Number L Type Irr Das Pub S Score S Score S Score <br /> Distance to WetL(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R cacti tion R condition R condition <br /> V. Site feature - Leaching Potential AnalYsis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Q Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxu 26-40\2 <br /> Man-Made conduits which increase vertical migration None Unknown Present <br /> of le2chate (i.e., septic systems, water wells, ponds) <br /> Unique site features: Recharge area, coarse soil, nearby wells. Q At least More than <br /> xxxxxx None I one one <br /> COLUMN TOTALS»>TOTAL POINTS `� 5 �/ <br /> Sample Result: (8 T X OR E) RANGE OF TOTAL POINTS 49 pts or more is 40 pts or less <br /> �_j T I. D x = ' "'X B T X E B T X E <br /> ff- r_ �' MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 _ .3 .3 1. 1. NA\3 <br /> Sample Result: <br /> GASOLINE 1000 100 10 <br /> _ -7 5 <br /> MAXIMUM ALLOWABLE TPN LEVELS (PPM) DIESEL 10,000 1000 100 <br /> _ aTPN <br /> FOOTNOTES: •'•If documented soil ardor groud water contamination is present, do not complete the Leaching potential <br /> analysis- (1.e., site is currently on UGT Contamination List for soil or grand 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 TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPN Concentrations > Allowable Levels *Yes I Kmo= <br /> 2. Recommend Site Closure Yes No � 'If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOM0KENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 30 (UGTWKSHT)\5/90 <br />