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SAN JOAQUIN i rr PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE; (VISION <br /> JORKSHEET FOR SITE CLOSURE EVALUATION DA,E <br /> NAME OF fACILI TY GY' -6) �_ 'LJ L ,� � SNEEPS CODE G� <br /> ADDRESS I/ -- TANK ID N T <br /> TANK SIZE -L-SQU FUEL TYPE <br /> .5� <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit # - Facility Status Code Doe.Soil/G4 Cont Yes No <br /> (Number of Tanks at facility / Age of Tanks(if available) y Type of Tank Steel Fbrgl Sngl Dust <br /> Ill. TANK HISTORY <br /> Was Tank tested? Yes No IX <br /> Failed precision test 7 Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes Mal <br /> Were soil samples analyzed? Yes No BTXE (TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION S TE DET ILS COLLECT T CHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water R© Ref/Year l?4. Average Akvw t Precipitation A* 14 10-25 <br /> On-Site Welt(s) Yes No Number & Type Irr Dam Pub <br /> 5 Score S Score S Score <br /> Distance to Wells) from Tank LD&D ft; _r, CJ ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition Rcondition <br /> V. Site Feature - Leaching Potential AnalysisE is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet)dC_�0._ >100 51-100 "+� 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Lr Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknown r Present <br /> Unique site features: Recharge area, coarse sail, nearby welts. At least More than <br /> xxxxxx None one one <br /> � u <br /> COLUMN TOTALS>»TOTAL POINTS 10 + r a <br /> ' <br /> Sadjle suit: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 4 40 pts or Less <br /> B TX E B T X E <br /> U MAXIMUM ALLOWABLE S-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> i TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented sail and/or grand 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 c5 ft., do not use table. <br /> \2 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 (diesel). <br /> V1. STAF� RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure)Yesl INoN1111*If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A 95'ERVISOR/5 IOR <br /> No <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE IYES rfNO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / Z iOATE CLOSURE LETTER MAl LED / / <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />