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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION 1' WORKSHEET FOR SITE CLOSURE EVALUATION DATE INANE OF FACILITY � CODE Z3�S%� ADDRESS c'�y) TANK ID o - C 71 _ TANK SIZE FUEL TYPE OL 11. GENERAL S e -T •�♦ Is permit current? Yes No ermit ! - Facility Status Code l7'7 Dec.SOiL/GW Cont Yes No Number of Tanks at facility Age of Tanks(if available) 35 ` ✓ Type of Tank Steel X Fbrgl Sn9l Dual Was Tank tested? as No Fatted precision test 7 Yes Ref/Year No If yes, give date(s) 14 Was a repair made to the tank system? Yes No 1 NrIf yes, what was repaired? Was repair done under insspectim7 Yes Irr No Dom were soil samples analyzed? Yes 5 C 0 R E No s C 0 R E BTXE S C 0 R E TPH-G Distance to Wells) frac Tank TPN•D Pb/EOB V. Site Feature - Leaching Potential Analysis Type of failure/discharge catastrophic long-term Leakage S overfill Fractures in subsurface (applies to foothills or mountain areas) unknC%n None other: of. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) Soil Samples Received Yea I V1. STAFF RECOMMENDATION/CONCLUSION 1. Are BTX 4 E or TPN Concentrations > Allowable Levels *Yes No 2. Recommend Site Closure Yes No 'If Yes, Refer to Site Mitigation for Evaluation VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/S�FNICR CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES No Depth to Ground Yater yJ Ref/Year S6 Average Arcual Preeip ltation A• 14 10-25 On -Site Wells) Yes � No Nurber i Type Irr Dom Pub 5 C 0 R E Score 10 pts if condition is met s C 0 R E Score 9 pts if condition is met S C 0 R E Score 5 pts if condition is met Distance to Wells) frac Tank �0 ft; ft; ft V. Site Feature - Leaching Potential Analysis Minimum Depth to grourdwater from the Soil Sa ote (feet) >100 51-100 S 25-50\1 Fractures in subsurface (applies to foothills or mountain areas) None / Unknown Present Average Annual Precipitation (inches) xxxxxxl <10 9 10-25 xxxzxxx 26-40\2 Man -Made conduits which increase vertical migration of leachate (i.e., septic systems, water wells, ponds) None Unknown Present Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None At least±tC).0r* oneone than COLUMN TOTALS>>>TOTAL POINTS a 7-1 a Sample Result: IS T X OR E) C_ -ooir y f >', 0 56 T= ,f9 5 RANGE OF TOTAL POINTS 49 pis or more 41 - 48 pts 40 pts or less MAXI NUMALLOW(BLE B -T -X -E LEVELS (PPM) B 1 T 50 X 50 E 50 B .3 T .3 X 1. E 1. XA\3 Sample Result: SID C)(')NAX]ML41 TPH GASOLINE ALLOWABLE TPX LEVELS (PPM) DIESEL 1000 100 10 10,000 1000 100 FOOTNOTES: "elf documented soil ardor ground water contamination is present, do not comptete the leaching potential analysis. (i.e., site is currently an UOT Contamination List for soil or ground water.) \1 If depth is > 5 ft. and < 25 ft., &Core 0 points. If depth «5 ft., do not use table. \2 If precipitation is > 40 inches, score 0 points. \3 Levels for STX3E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppa (diesel). V1. STAFF RECOMMENDATION/CONCLUSION 1. Are BTX 4 E or TPN Concentrations > Allowable Levels *Yes No 2. Recommend Site Closure Yes No 'If Yes, Refer to Site Mitigation for Evaluation VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/S�FNICR CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES DATE REFERRED DATE LOSUR€ LETTER MAILED / / NAME OF EVALUATOR EH Z3 30 (UGTWKSHT)\5/90