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SAN JOAQUIN Cd) PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALT iVISION <br /> ), <br /> U.WORKSHEET FOR SITE CLOSURE EVALUATION � DATE //—/& —y'a4f <br /> NAME OF FACILITY ` SWEEPS CODE <br /> �..7 <br /> ADDRESS ©O3 F_ H� {/1'IJ, TANK 10 213��97F-_15�1 <br /> TANK SIZE S FUEL TYPE je (gyp�(�(�liyGC.{it7 t�er(/ <br /> 11. GENERAL SITE HISTORY <br /> 11 <br /> Is permit current? Yes x No Permit #1� 9 Q"/ Faculty Status Code oe.Sol l/GY Cont Yea No <br /> Nurber of Tanks at facility Age of Tankad f available) Type of Tank Steel Fbrgl Sngt Dual Li <br /> fit. TANK HISTORY <br /> Was Tank tested? Yes No Fatted precision test 7 Yes - No If yes, glue date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done Isder inspection? Yes No Were soft samples analyzed? Yes No BIKE TPN-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill 1XIunknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water Rei/Year Average Arcual Precipitation A• 14 10-25 <br /> On-Site Wells) Yes No Number 6 Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 If 0 If <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E Is met E is met <br /> Minimum Depth to groundwater from the Solt Sample (feet) 60 1 Vq Y '100 51-100 25-50\1 <br /> Fractures In subsurface (applies to foothills or mountain areas) None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx 00 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 16 Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one 1 ? one <br /> COLUMN TOTALS»'TOTAL POINTS I D - q IS = J Y <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or leas <br /> t3 > 0,#47 r= . o7o <br /> B T X E B T X E <br /> X— 110 t ' 0,3 1-'— MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. NA\3 <br /> Sample Result: TB3 E GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH-0 DIESEL 10,000 1000 100 <br /> FPO <br /> FOOTNOTES: -**If documented soft end/or ground water contamination is present, do not complete the leaching poten a <br /> analysts. (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 <=5 ft., do not use table. <br /> \2 if precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at s TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX d E or TPH Concentrations > Allowable Levels 'Yes _ No <br /> 2. Recommend Site Closure Yea No •If Tee, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREYES LfN01 REFERRED TO SITE MITIGATION FOR EVALUATION YES VINCI <br /> DATE REFERRED ('L./ 3 0 / t? 7. DATE CLOSURE LETTER NAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />