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SAN JOAQUIN CCUN'.. LIC HEALTH SERVICES/ENVIRONMENTAL HEALTH 0 ION - — <br /> UGS,-':TRKSHEET FOR SITE CLOSURE EVALUATION + DAT° / , <br /> SLEEPS CODE �/ <br /> SAME OF FACILITY <br /> S TANK ID Y ISJ <br /> 00RESSI O/ <br /> . GENERAL SITE HISTORY Y <br />, Na <br /> FIs permi[ current? Yes No Permit B - Facility Status Code Doc.Soi l/GL Cont Yes <br /> IHulber of Tanks at facility Age of Tanks(if available) Type of Tank steel Fbrgl Sngki Dual <br /> II. TANK HISTORY <br /> �Las TanK [anted? Yes No Failed precision test 7 Tes No If yes, give daces) <br /> If yes, what was repaired? <br /> Was a repair made to the tank system? Yes No <br /> Was repair done under inspection? Yes Mal Were soil saaplea ara lyzed7 Yes No BTXE TPH-G ITPx•0 Pb/EDB <br /> II <br /> I Type of failure/discharge catastrophic long-cera leakage) overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Sams R <br /> pleeceived Yes No Depth to Grourd Vater Ref/Year , <br /> Average Arcual Precipitation A• 14 10-25 <br /> On-Site VeIL(s) Yes No Number i Type lrr Daa Pub <br /> S Scare s score s Scare <br /> Distance to Vett(s) frac Tank fT; ft; ft 0 if pts 0 ifpts 0 ifpta <br /> R condition R condit{an R condition <br /> E is act <br /> v. Site Feature - Leaching Potential Analysis E is met E is met <br /> Minimm Depth to groundwater frac the Soil Sample (feet) <br /> >100 51-100 25-50\1 <br /> Fractures in subsurface (applies Co foothills or mountain areas) <br /> More Unknown Present <br /> Average Annual Precipitation (inches) Xxx= 410 9 10-25 xxxxxxx 26-40\2 <br /> Man-made conduits which increase vertical migration More Unknown Present <br /> of Leachate (i.e., septic system, water wells, ponds) <br /> At Least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx more one am <br /> COLl1W1 TOTALS»>TOTAL POINTS ` <br /> A <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 4a pts 40 pts or Less <br /> � N,Q S _ B T X E g T X <br /> A P- E <br /> II - " MAXiM1A1 ALLOWABLE g-T•%•E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. mA\3 <br /> sample Result: <br /> GASOLINE 1000 100 10 <br /> .36 m 37 MAXIMlA1 ALLOWABLE TPH LEVELS (PPM) DIESEL 10,000 1000 100 <br /> p rpx <br /> FOOTNOTES: •••If documented soil and/or ground water contaminwndan Is present, do not coaplete the leaching potential <br /> analysis. (I.e., site is currently on UGT Contamination List for soil or grand water.) <br /> %I If depth is > 5 ft. and 4 25 ft., score 0 points. if depth "S ft., do not use table. <br /> \2 If precipitation is > 40 Inches, score 0 points. <br /> n \3 levels for STXSE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECO WENDATION/CONCLUSION S P- r AAD <br /> SP- 3f = � OPPvw <br /> 1. Are 3T7( i Ear TPN Concentrations > Allowable Levels 'Yes No 7 rml <br /> 2. Recommend Site Closure Yes No -If Yes, Refer to Site Mitigation for Evaluation s 6 f �0 wl-) <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A suPERV1SOR/SENIOR <br /> CCNCJR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> GATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF n V <br /> EVALUATOR <br /> EN 23 30 (UGTVKSHT)\5/90 <br />