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SAN JOAQUIN ,,Ty PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA../DIVISION I - ^ <br /> I UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATEI /� p <br /> NAME OF FACILITY I C/'7 F Q ` C� Iswan CODE( �3 /D?CP <br /> ADDRESS _3 +7 S, U k C (TANK ID 913 9 - !� ��•- <br /> TANK SIZE D OQ 0 FUEL TYPE I <br /> II. GENERAL SITE HISTORY / <br /> I permit current? Yes I X Na Permit # - Facility Status Code!0 1 Doc.Soil/OW Cant Yes No <br /> Number of Tanks at facilityAge of Tanks(if available) Type of Tankl Steel Fbrgl Sngl Duet <br /> III. TANK HISTORY <br /> Was Tank tested? Yes x <br /> No (Failed precision test ? Yes No X1if yes, give dare(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection?i Yes No Were soft samples analyzed7lyesI INoI I BTXE ITPN-G I I PH-D I Pb/EDB <br /> Type of failure/discharge catastrophic ILong-term leakage IoverfiLL unknown Iother: <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 IRef/Year Average Arsuel Precipitation A= 14 10-25 <br /> On--Site Wetl(s) Yes No Number 8 Type Irr Dom PUbI <br /> S Score S Scare S Score <br /> Distance to WQLL(s) from Tank) ft; ft; ft C 10 pts C 9 pts C 5 pis <br /> O if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching PotentiaL Ana Lysis E is met c is met E is met <br /> Minimum Depth to groundwater from the Sail Sade (feet) I >100 I I51-100 I ( 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) I More I Unknown Present <br /> Average Annual Precipitation (inches) Xzza:ot 00 I 9 ! 10-25 Ix:uocxxx� 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, pods) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. I At Leastl more than <br /> Xx)OnXX More ane are <br /> 'r K3 0 T- N+p� ED Q - �l. y /Ax-.5- g I'CDLUM TOTALS»>TOTAL�POINTS i a <br /> Sample Resut t: (B 7 X OR E) RANGE OF TOTAL POINTS 49 pis or more 41 4$ pts 40 pts or less <br /> 30 porn <br /> D <br /> {2 ; "O 8 T X E 3 T X E <br /> L U MAXIMUM ALLOWABLE B-T-X-c LEVELS (PPM) 1 50 50 50 .3 (.3 t. t. NA, <br /> Sam a R1 uLt: GASOLINE 1000 100 10 <br /> y g � n MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> Y DIESEL 10,000 IWO 100 <br /> FOOTNOTES: If documented sail and/or ground water cmtaminatim is present, do not complete the Leaching potential <br /> analysis. (i.e., site is currently an UGT CoMainatim List for sail w grand water.) <br /> \1 If depth is > 5 ft. and < 25 ft., scare 0 points. If depth a5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, scare 0 points- <br /> \3 Levels for STXdE 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 > ALLoweble 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 YESI INOI IREFERRED TO SITE MITIGATION FOR EVALUATION YES! NOI <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILEDI <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />