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SAN JOAQUIN Cpm,/! PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA�IVISION <br /> (GST WGRKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY (SWEEPS CCOEI `j <br /> ADDRESS( TANK ID x 3 - 'l c, <br /> j TANK SIZEI Al, DD� FUEL TYPE( (2,650JJ�� �V� <br /> :i. GENERAL SITE HISTORY <br /> is permit current? Yes Na IxPermit 3 - Facility Status Code �l Doc.SoiL/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks0 f available) U*op' I <br /> Type of Tank I steel FbrgL Sngt Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? Yes No M <br /> Failed precision test ? Yes NoI if yes, give date(s) <br /> Was a repair made to the tank systam2 Yes No XIf yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yesl NoI BTXEI ITPH-G TPH-D Pb/EDB <br /> Type of failure/discharge) catastrophic (tong-tern leakage Ioverfitl unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes NaDepth to Ground Water /1U IRef/Year) 8�p Average Arcual Precipitation A= 14 10-25 <br /> On-Site WeIL(s) Yes No Number 8 Type Irr Dom Publ <br /> 5 Score S Scare S Score <br /> Distance to WeIL(s) from lank 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 AnalysisE is met C is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) P--qq- I >100 I 67 151-100 I I. 5-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) V I None I I Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 110-5 Ixxxxxxx 26-40\2 <br /> Man-made conduits which increase vertical migration <br /> of leachate (i.e., septic system, water wells, ponds) Nne oUnknown Present <br /> Unique site features: Recharge area, coarse sail, nearby wells. I At Least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS 1 D ' 3 CO ' D = �(a <br /> Sample ^Result: IS T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> 3 T I X I E 3 I T X 1. <br /> E <br /> MAXIMUM ALLOWABLE 3-T-X-E LEVELS (PPM) 1 So 50 50 3 .3 1. NA\3 <br /> S le Re ult: GASOLINE 1000 100 10 <br /> Ta, <br /> 1 <br /> 3-300 MAXIMaM ALLOWABLE TPH LEVELS (PPM) <br /> (1 W $Sp TPH D DIESEL 10,000 1000 100 <br /> FOOTNOTES: —If documented soil and/or ground water contamination is present, do coop ere a leaching potenti aL <br /> analysis. (i.e., site is currently on UGT Commination List for soil or ground water.) <br /> \1 if depth is > 5 ft. and < 5 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 BTXLE are not applicable at a TPN concentration of 10 ppm (gasaline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels 'Yw Na <br /> 2. Recommend Site Closure Yes (NoI I•'If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO SE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YESI NOI IREFERRED TD SITE MITIGATION FOR EVALUATION YESI NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />