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P <br /> Y <br /> SAN JOAQUIN L*..3Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL 4E&�AIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> NAME OF FACILITY `/ - CO-L / N� ISUEEPS CODE( <br /> AOORESS / S' (TANK 10 A•I CO <br /> TANK SIZED-/, C)QQ (FUEL Type J <br /> It. GENERAL SITE HISTORY <br /> is permit current? Yes No Permit X - facility Status Code 4 1q Ooc.Soil/GW Corr Yes NO <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank I Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No X Failed precision test 71Yes No If yes, give date(s) <br /> Was a repair made to the tank system! Yes Na If yes, what was repaired?I <br /> Was repair done under inspection? Yesl No Were soil samples analyzed? Yesl INoI BTXE ITPH-G TPH-0 Ph/EDB <br /> Type of failure/discharge) catastrophic (long-term Leakage Ioverfi LLI IUnknown l other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> SoiL Samples Received Yesl No Depth to Ground Water Ret/Year / (Average Annual Precipitation A=I14 110-25 <br /> On-Site Wells) Yes No IML ber 3 Type Irr low I Publ N <br /> 5 Scare S Scare S Score <br /> Distance to Wells) Pram Tank ft; _f t; ft C 10 pts C 9 pts C 5 pts <br /> O if 0 if 0 if <br /> R condi Li an R condition R condition <br /> V. Site Feature - Leaching PoteiiiaL AnaLysis E is met _ is met E is met <br /> IMinimam Depth to groundwater from the Soil Sample (feet) qq, I >100 I 151-100 I.25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) I None I I Unknown Present <br /> Average Annual Precipitation (inches) xxx j <10 I 9 110-25 lxxxxxxxl 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> .of leachate (i.e., septic system, water wells, ponds) More Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At Least) More than <br /> xxxxxx None one we <br /> COLUMN TOTALS»>TOTAL POINTS + + s = <br /> Sano Le Result: (S T X OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 - 48 pts s <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 9 50 50 50 .3 !.3 1. 1 NA\3 <br /> SanplppResut `'�./ef,L , IMDI ALLOWABLE TPH LEVELS (PPM7 GASOLINE 1000 I 100 70 <br /> ](a lY�� DIESEL 10,000 I 1000 100 <br /> FOOTNOTES: "'"'If documented soil arid/or ground water contamination is presort, dm not complete the leachr tential <br /> analysis. (i.e., site is currently on LIST 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. <br /> \3 Levels for 8TX3E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (dieset). <br /> VI. STAFF RECOMMENDATION/CCNCLUSIOM <br /> 1. Are BTX 8 E or TPH Cancortrations > Allowable Levels 'Yes No .•GC L(,Q� ��dX UI�Ce� <br /> 2. Recommend Site Closure les No I''If Yes, Refer to Site Mitigation for Evaluation -P/7sse <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR ENTOR ' -�' L <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YESI NOI IREFERRED TO SITE MITIGATION FOR EVALUATION YES( INOI <br /> DATE REFERRED / / ( DATE CLOSURE LETTER MAILED( / / <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />