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c <br /> SAN JOAQUIN TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE DIVISION <br /> I `rST WORKSHEET FOR SITE CLOSURE EVALUATION '� DATE <br /> NAME OF FACILITY C.�/'TA-1 �0r Ivan CODE) ��3!U �`L, <br /> ADDRESS 3/ 4/ 7 �] o I TANK ID <br /> TANK SIZE /0 Z)OO FUEL TYPE LG'N <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Yesl No (Perm 3 - Facility Status Code Dec.Soil/GW Cmtes YNo <br /> Number of Tanks at facility Age of Tanks(if available) Type of TanklSteel Fbrgl jj <br /> Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes NiNo (Failed precision test 7 Yes No /N if Yes, give date($) / / <br /> Was a repair made to the tank system?lYes No if yes, what was �rep`laired? <br /> Was repair done under inspection?I Yes No Were soil samoles analyzed? Yes INoI I BTXE (TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic hong-term leakage loverfill unknown lather: <br /> i <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No (Depth to Ground Water )Ref/Year Average Annual PrecipitationlA= 14 10-25 <br /> On-Site Wel l(s) Yes No Number 4 Type Irr Dam IPubI <br /> 5 Score S Score S Score <br /> Distance to Wells) 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 _ is met <br /> Minim Depth to groundwater from the Soil Sample (feet) >100 l 151-100 I 125-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) ' Unknown l I Unknown (Present <br /> Average Annual Precipitation (inches) -;;; a <10 i 9 110-25 X%X%XXXI 25-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic system, water wells, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. I At least) More than <br /> )000= Mane one one <br /> 1' Koa.E IRW F-DB <br /> P COLUMN TOTALS»TOTAL POINTS + <br /> Saqge Result: (317 X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts l 40 pts or less <br /> Kdw = f�ii ND <br /> B T I % E 3 T X E <br /> MAXIMAL ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 i. i. NA\3 <br /> S � }e Result: n� GASOLINE 1000 100 I 10 <br /> `�/'�pZ 6. I,aQoYn MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPN� DIESEL 10,000 1000 100 <br /> FOOTNOTES: ' If documented soil and/or ground "ter contamination is present, do not crno/ete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground "ter.) <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 BTXSE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOLMEHOATION/CONCLUSIGN <br /> 1. Are BTX 8 E or TPH 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 /> CCNCUR WITH STAFF RECOMMENDATION FOR CLOSURE(YESI NOI IREFERRED TO SITE MITIGATION FOR EVALUATION YES( JNOI I <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED( <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />