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SAN JOAQUIN COUNTY .IC HEALTH SERVICES/ENVIRONME4TAL HEALTH 0; ON DATE <br /> UGST 'MiCSHEET FOR SITE CLOSURE :VALUATION • w <br /> 4ANE OF FACILITY <br /> ))__C) `/[ sC SLEEPS CODE <br /> DOR_S<-S l TANK I D Y <br /> ANK SIZE FUEL TYPE t7 <br /> hewoved <br /> GENERAL SITE HISTORY ••• <br /> Its permit current? Yes No Permit s Facility Status Code Doo.SOit/Gw Cont Yes No <br /> 4utber of Tanks at facility Age of Ts(if available) Wx_k_Type of Tank Steel Fbrgl Sngl Dual <br /> aok <br /> i. Ll <br /> TANK HISTORY <br /> gas Tank tested? Yes No Failed precision test T Yes No If yes, give date(s) <br /> was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Las repair done under inspection? Yes No were soil saapLet analysed? Yesl No BTXE TPN-G ITPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakagel overfill unknown other: <br /> '.V. REMCVAL HISTCRY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) _ <br /> A ; Average Annual Precipitation A• 14 10-25 <br /> Soil Samples Received Yes No Depth to Ground water lJ Ref/Year <br /> lCn•Site Wallis) Yes No Number G Type Irr Dao Pub S Score S Score S Score <br /> Distance :o Wallis) from Tank ft; ft; ft C 10 pts C 9 pts C Sfpts <br /> 0 if 0 if 0 <br /> R condition R condi ti on R Condition <br /> V. Site Feature - Leaching Potential Analysis <br /> E is met E is met E is Diet <br /> Minimm Depth to groundwater from the Soil Sample (feet) >100 51-100 <br /> 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain arses) <br /> None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 I 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration None Uramw �L, Present <br /> of leachate (i.e., septic systems, water wells, ponds) <br /> Unique site features: Recharge area, coarse soil, nearby wells. Xzxxxx None q At least More thanane °M <br /> COL@W TOTALS>»TOTAL POINTS 10 • I '�) a 3? <br /> Sample Result: (B 7 X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T X E <br /> MAXIALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 SD .3 .3 1. 1. NA\3 <br /> Sample Result: <br /> GA CLINE 1000 100 10 <br /> MAXIMUM ALLOWBLE TPN LEVELS (PPM) 100 <br /> iPN DIESEL 10,000 1000 <br /> FOOTNOTES: ...if documented soft 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 4-5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. fr ppm (diesel). <br /> \3 Levels for XSE are not applicable at a CPN concentration Of n1e �G'i'UM 100, / - <br /> Vt. STAFF RECOMMENDATION/CONCLUSICN <br /> //e p/ CToo h-n�, J <br /> 1. Are 3TX i E or TPN Concentrations > Allowable Levels 'Yes No <br /> C�Ppr•.. <br /> 2. Recomaend Site Closure Yes No •If Yes, Refer to Site Mitigation for Evaluation <br /> .gad = �5pp>Fti -� <br /> VI1. REVIEW EVALUATION - TO BE CC14PLETED BY A suPERVISCR/SENICR <br /> CONC_'R WITH STAFF RECOMMENDATION FOR CLOSURE TES NO REFERRED TO SITE MITIGATION FOR EVALUATICN YES NO <br /> DATE REFERRED / / '�2 DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 30 (UGTLKSHT)\5/90 <br />