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SAN JOAQUIN ITY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE DIVISION <br /> I �ST WORKSHEET FOR SITE CLOSURE EVALUATION 4! DATE( <br /> NAME OF FACILITY l �� (SWEEPS CODE( <br /> ADDRESS (TANK LD d13 - , a... <br /> TANK SIZE ZG WO FUEL TYPE D * <br /> It. GENERAL SITE HISTORY `j'}IIV Yl'7 G..C.OcGL(JC,� <br /> Is permit current? Yes No Permit N - Facility Status Code Q / Dac, it/GW Cant Yes No <br /> Number of Tanks at facility (Age of Tanks(if a-vlailable) u Type of Tank ISteel Fbrgl Sngl Dual <br /> III. TANK HISTORY 4" <br /> Was Tank tested? Yes F No Failed precision test ? Yes lNo If yes, give clarets) <br /> Was a repair made to the tank system? Yes No If yes, whatwas repaired? <br /> Was repair done under inspection?I Yes No Were saiL samples analyzed? Yesl INo( I BTXE ITPH-G TPH-D Pb/EDB <br /> Type of failure/discharge wtastraphic (long-term Leakage Ioverfi ll unknown) lather: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No IDepth to Grand Water 5I Ref/Year Ed, Average Annual Precipitation A- 14 10-25 <br /> On-Site WeLL(s) Yes No Number S Type Irr am )pub S Scare S Sears S Score <br /> Distance to Well(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 Analysis3�--/Spr�D E is met is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) I >100 I I51-100 I I 5-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) i0:1 None I Unknown (Present <br /> Average Annual Precipitation (irudtes) Ixxxxxx 00 I 9 110-25 xxxxxxxl 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of Leachate (i.e., septic systems, water wells, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby welts. At least More than <br /> xx)o= None one we <br /> COLUMN TOTALS»>TOTAL POINTS a O . 1 I c = _� 1 <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts s or <br /> 9'x. �= x -fka .5so <br /> B T X I E B T X E <br /> y <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 3 .3 i. 1 NA\3 <br /> Sample Result(,pg/l2� MAXIMUM ALLOWABLE TPN LEVELS (PPM) GASOLINE 1000 100 M0 <br /> Ka OTPH D DIESEL 10,000 1000 100 <br /> FOOTNOTES: —If documented soil and/or ground water contamination is present, do not complete the ing potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or grand <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth a5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXdE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diese(). <br /> VI. STAFF RECOMMENDATION/CONCLUSION �.�i n 4 / 170lJPbeB//t NL <br /> 1. Are 8T7( & E or TPN Concentrations > Allowable Levels -Yes XNa <br /> 2. Recommend Sire Closure Yes INo If Yes, Refer to Site Mitigation for Evaluation - / N D Or/tki"P <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR CC <br /> CCNCUR WITH STAFF RECOMMENDATION FOR CLOSURE TESI INOI IREFERRED TO SITE MITIGATION FOR EVALUATION YES( INOI <br /> DATE REFERRED / / DATE CLOSURE LETTER NAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 h ����� a <br /> JVD i3 7?(Y <br />