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SAN JOAQUIN .TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HI DIVISION <br /> 1, �1GST WORKSHEET FOR SITE CLOSURE EVALUATION _- DATE / I-�(, <br /> NAME OF FACILITY -fp G 14&11.� S tt=L. _� SWEEPS CODE ��8 <br /> ADDRESS 3003 E. ga/n,yyt,QhJ Grv, TANK ID R U9� - a-- <br /> TANK SIZE FUEL TYPE L-tjYfil QiLf � Q �'7—_. <br /> It. GENERAL SITE HISTORY <br /> u. <br /> Is permit current? Yes M <br /> No Permit A b Facility Status Code Doc.Soil/GW Cont as No <br /> Number of Tanks at facility Age of Tanks(If available) , Type of Tank Steel Fbrgl Brat Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? Yes No 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? U.Cy Ocz i 2)15?la in <br /> Was repair done under inspection? Yes Noix I Were soil samples analyzed? Yes No BTXE TPH-G TPH-0 Pb DB <br /> Type of failure/di seherge cetastroph is tong-term leakage overfill Unknown xother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to GrMR <br /> ; Average Annual Precipitation A• 14 10-25 <br /> On-Site Wells) Yes No Nunber d Type Score S Score S Score <br /> Distance to Well(s) from Tank ft; 10 pts C 9 pts C 5 pts <br /> if 0 if 0 if <br /> condition R condition R condition <br /> V. Site Feature - Leaching Potential AnalysisIs met E is met E Is met <br /> Minimum Depth to groundwater from the Solt Sample (feet).- l 69-4#1 ,100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) ' None Unknown J 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 Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one II one <br /> COLUMN TOTALS»,TOTAL POINTS ' G * <br /> Semple Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> AlD B T X E B T X E <br /> /(/ MAXIMUM ALLOWABLE B-7-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. MA\3 <br /> Sample Result: T4.2 GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPN LEVELS (DPM) _ <br /> TPN-D DIESEL 10,000 1000 100 <br /> FOOTNOTES: '*•If documented soil and/or ground water contamination is present, do not coaplete the leeching po en al <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 <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXEE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX t E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED 2 /�O / 5 Z_ DATE CLOSURE LETTER NAILED / / <br /> NAMEOF () <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />