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SAN JOAQUIN COUW_ .UBLIC HEALTH SERVICES/ENVIRONMENTAL HEALT" 'VISION DATE 8— O / <br /> Ut�JORKSHEET FOR SITE CLOSURE EVALUATION ...i <br /> • SWEEPS CODE ,(f. 3 <br /> ,E OF FACILITY <br /> ,DDRESS aTANK <br /> y-�I D,,# �9Q y -6 <br /> TANK SIZE 3,5,5 b FUEL T Q <br /> It. GENERAL SITE HISTORY 0 +++ <br /> Is permit current? Yes No ` Permit # - Facility Status Code Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank SteelFbrgl Sngl <br /> A9471p <br /> Duel <br /> 111. TANK HISTORY G(/ <br /> �T7 0 <br /> Was Tank tested? Yes No xI Felled precision test ? Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair dans under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown 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' b Ref/Year , Average Annual Precipitation A= 14 10-25 <br /> On-Site Well(s) Yes No Nunber L Type Irr Dom Pub S Score S Score S Score <br /> Distance to Wells) from Tank ,l,�f t; 6 .00 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 Soil Sample (feet) 670 — >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) " tj None kO�205 <br /> nwn Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 - xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration None Unknown S Present <br /> of leachate (i.e., septic system, water wells, ponds) <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least r/� More than <br /> x)xxxxx None Jwe <br /> ! <br /> COLUMN TOTALS>>>TOTAL POINTS O t 13 <br /> nne+ I v 3? <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> j�yiT nib <br /> I� frM a T X E B T % E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. MA%3 <br /> Sample Rgqstlll:: iPrn WSOIINE 1000 100 10 <br /> (Ott-}`� cLt+�A- MAXIMUM ALLOWABLE TPN LEVELS (PPM) DIESEL 10,000 1000 100 <br /> at <br /> FOOTNOTES: -**If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> %I 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. ppm (gasoline) or 100 (diesel). <br /> \3 Levels for STXBE are not applicable at a TPH concentration ''of1110 ppm <br /> VI. STAFF RECCMMENDAT ION/CONCLUSION W'w'� �ecl /eylJ � <br /> 1. Are BTX 8 E or TPN Concentrations > Allowable Levels -Yes No Ua �' m�K - <br /> f,(, <br /> 2. Recommend Site Closure Yes Na •If Yes, Refer to Site Mitigation for Evaluation _ <br /> F4 77 <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECCMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> GATE REFERRED / / DATE CLOSURE LETTER NAILED <br /> NAME OF <br /> EVALUATOR <br /> EX 23 80 (UGTWKSHT)\5/90 ., // . /f �/-N 1 y� R�'jY S�'� <br /> All ( ////���/Jd� n // Dr�/7 w <br />