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SAN JOAQUIN Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA: J[VISION <br /> I. GST WORKSHEET FOR SITE CLOSURE EVALUATION +•J DATE — <br /> NAME OF FACILITYY7 1 <br /> Cz1-( SWEEPS CODE (P <br /> ADDRESS t- TANK ID # tj - / b ! ala <br /> TANK SIZE � � <br /> / 000 FUEL TYPE � (O O <br /> II. GENERAL SITE HISTORY zxt1).�a�� <br /> wK <br /> Is permit current? Yes No IYIPeMmi N - Facility Status Cade Dac.Soil/GW Cont Yes No <br /> Number of Tanks at facility ge of Tanks(if available) k,4,k Type of Tank l Steel Fbrgl SngL D <br /> 11I. TANK HISTORY <br /> Was Tank tested? Yes No Failed precisi test ? Yes No It yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were sail sampLes analyzed? Yes No BTXE IT -G I TPX-D Ph/EON <br /> Type of failure/discharge catastrophic long-term akage overfill I unknown I other• <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAI /COLLECT DATA FOR LEACHING POTEX L ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water Ref/Year �� A l Precipitation A- 14 10-25 <br /> On-Site WeLL(s) Yes No Number & Type Irr Dam jPubj <br /> SS Score S Score <br /> Distance to Wells) from Tank ft; ft; f C s C 9 pts C 5 Pts <br /> 0 0 if 0 if <br /> Rcondition R condition R condition <br /> V. Site Feature - Leeching Potential Analysis P is met E is met E is met <br /> Minimum Depth to groundwater from the Soil S (feet) >100 51-100 25-50\1 <br /> Fractures in subsurface (app fN i)Ls tain are None Unknown Present <br /> Average Annual Precipit i (i ) xzxxxx <IO 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which inc ease vertical migration <br /> of leachate (i.e., septic systems, water wells, PoyxLs) Non Unknown Present <br /> Unique site features: Recharge area, coarse it, nearby wells. At Least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS TOTAL POINTS * + <br /> Sample ResuLt: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 1 - 48 pts 40 pts or less <br /> B T X E B X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPX DIESEL 10,000 1000 100 <br /> FOOTNOTES: " if 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 c5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPM Concentrations > Allowable Levels *Yes No <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 RECOMMENDATION 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 /> EM 23 80 (UGTWKSHT)\5/90 <br />