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SAN JOAQUIN `rTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA,`OIVISICN <br /> I• UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE eS <br /> AME OF FACILITY �( r14 <br /> LLA ECORD ID .7/� 9� <br /> DRESS S"Qel l�7 S ✓ ANK [D d - / <br /> ANK SIZE I IFUEL TYPE <br /> If. GENERAL SITE HISTORY <br /> s permit current? es o ermit # - acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility Be of Tank(if available) �fype of Tank teel Fbrgl rgl Dual Lj <br /> 111. TANK HISTORY <br /> as Tank tested? as o ailed precision test ? as o If yes, give date(s) <br /> as a repair made to the tank system? es I No f yes, what was repaired? <br /> Jas repair done under inspection? es �lo ere soil samples analyzed? es o TXE I PH-G I IrPH-o b/EDB <br /> ype of failure/discharge atastrophie tang-term leakage verfill they: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Grand Water of/Year verage Annual Precipitation 4 0-25 <br /> Site Wells) es o umber & Type Irr am ub <br /> S core S core 5 core <br /> F <br /> stance to WeII(S) from Tank ft; ft; ft C 0 pts C pis C pts <br /> 0 f 0 1f 0 f <br /> R ondition R ondition R ondi tion <br /> Size Feature - Leeching Potential Analysis E 's met E is met -c s met <br /> inimam Depth to groundwater from the Soil Sample (feet) -- >100 1-100 I� 25-5011 <br /> raczures in subsurface (applies to foothills or maintain areas) NoneUnkrawn resent <br /> verage Annual Precipitation (inches) _ <10 9 1 10-25 x 26-4012 <br /> an-Made conduits which increase Vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> i cpue size features: Recharge area, coarse Soil, or wells. At least are than <br /> (Muncipal=>2000 ft; domestic=>500 £t; irr/agriculturalzpresent) 000OCK None one one <br /> COLUMN TOTALS»>TOTAL POINTS - <br /> Lj <br /> �a-jm-�p,�lr,/e/(Jgesult: (8 TT XfJOR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> e T % E B - % E <br /> / MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 X50 .3 .3 1. 1. NA\3 <br /> ample Result: SOLINE 1000 100 10 <br /> AXIMUN ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTES: —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 grovel water.) <br /> Al If depth is > 5 ft. and < 25 ft., score 0 paints. If depth c5 ft., do not use table. <br /> 12 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diene U. <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPN Concentrations > Allowable Levels Yes o (/i^ F�/lll---✓✓✓/* _S -l�Pw' ( 4 l <br /> 2. Recommend Site Closure as o If Yes, Refer to Site Mitigation for Evaluation po /e n / r'""'- _ <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 I EFERRED TO SITE MITIGATION FOR 'e VALUATION E ,j <br /> )ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> i <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />