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SAN JOAQUIN ( 'Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL NEA^DIVISION <br />�ST WORKSHEET FOR SITE CLOSURE EVALUATION ''� DATE (] -2,01 y <br />/' ' JA' _ p SWEEPS CODE <br />NAME OF FACILITY / P.cif� , <br />TANK SIZE IX �/. S/ <br />It. GENERAL SITE HISTORY <br />�— <br />IIs permit current? Yes <br />Number of Tanks at facili <br />III TANK HISTORY <br />FUEL TYPE <br />O <br />Permit fi - Facility Status Ca <br />Age of Tanks(if available) UI`r Type of <br />ID <br />Doe.SOil/GW Cont Yes IN <br />Steel Fbrg lSteel Fbrgl Sngl Dual <br />Was Tank tested? <br />YesnsysterN7 <br />No <br />Depth to Ground Water <br />Ref/Year <br />No! <br />No <br />If <br />yes, give date(s) <br />10-25 <br />Was a repair made to twhat <br />Yes <br />NAME OF <br />No <br />was repaired? <br />Number & Type <br />Was repair done under <br />Irr <br />Dan <br />Pub <br />MewVai <br />amples analyzed? <br />YeTPN-G <br />TPH-D <br />Pb/EDB <br />'Type of failure/dischage <br />overfill <br />Score <br />10 pts <br />unknown <br />Score <br />9 pts <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSP CTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHINU YUICNIIAL AMLT*LZJ <br />Soil Samples Received <br />Yes <br />No <br />Depth to Ground Water <br />Ref/Year <br />No! <br />Average Annual Precipitation <br />A= <br />14 <br />10-25 <br />On -Site Wells) <br />Yes <br />NAME OF <br />No <br />EVALUATOR <br />Number & Type <br />Irr <br />Dan <br />Pub <br />S <br />C <br />Score <br />10 pts <br />S <br />C <br />Score <br />9 pts <br />S <br />C <br />Score <br />5 pts <br />Distance to Wells) from Tank <br />ft; ft; ft <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />V. Site Feature - Leaching Potential Analysis <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />51-10o <br />O <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />10 <br />None <br />Unknown <br />Present <br />Average Annual Precipitation (inches) <br />xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />Nana <br />q <br />Unknown <br />Present <br />!of leachate (i.e., septic systems, water wells, ponds) <br />1 <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />At Least <br />Kom than <br />)DOOIxx <br />None <br />awe <br />a1ne <br />TOTALS>>>TOTAL POINTS <br />IV <br />Z� <br />• <br />0 <br />5-7 <br />COLUMN <br />iSample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />41 - 48 pts <br />40 pts or Less <br />B <br />T <br />X <br />E <br />B <br />T <br />X <br />E <br />!, <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />1 <br />50 <br />50 <br />I <br />50 <br />I <br />.3 <br />.3 <br />1. <br />1. <br />NA\3 <br />Sample Result: <br />GASOLINE <br />1000 <br />100 <br />10 <br />„/ <br />MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br />7 TPH <br />I <br />DIESEL <br />j <br />10,000 <br />Iwo <br />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 <--5 ft., do not use table. <br />\2 If precipitation is > 40 inches, score 0 points. <br />.:t & OTUDC ....I: ..gym_ res -4 in ....,, -.j inn id:ceemi <br />V(. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX & E or TPH Concentrations > Al able Levels *Yes VNo <br />2. Recommend Site Closure Yes No*If Yes, Refer to Site Mitigation for Evaluation <br />JIT. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISORfSENIOR / <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE <br />YES <br />NO <br />REFERRED TO SITE MITIGATION FOR EVALUATION <br />YES <br />No! <br />DATE REFERRED <br />1 <br />E CLOSURE LETTER (AILED <br />NAME OF <br />EVALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />