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• SAN JOAOUIN CAwWORKSHEET SERVICES/ENVIRONMENTAL NEALi'tIDIVI SI ON <br />ST FOR SITECLOSUREEVALUATION <br />ATE 17,`t 9 — <br />I. <br />EEPS CODE la -0 <br />0.ME OF FACILITY JCf [L- <br />ANK ID p <br />DDRESS �—a�-� c �AN Ck YLo U-Jv <br />II. <br />TANK SI2E I I GCOM <br />GENERAL SITE HIS <br />acy <br />UEL TYPE k <br />Lgfof� to <br />SAM -4t, <br />, • ^ � * � <br />ORY <br />of/Year <br />s permit current? <br />as <br />yes, give date(Sl) <br />o <br />as a repair made to the tank system? as No f yes, what was repaired? <br />ermit p <br />acility Status Code <br />as Roy <br />ere soil samples analyzed? <br />oc.Soi l/GWCont <br />as <br />)'umber <br />of Tanks at <br />facility <br />PH -G <br />ge of Tanks(if available) <br />PH -D <br />ype of Tank <br />teel <br />Score S <br />9 pts C <br />if 0 <br />condition R <br />is met E <br />Fbrgl <br />fstance to Well(s) from Tank <br />nqL <br />Dual <br />"I TANK HISTORY <br />verfill <br />nknown <br />as Tank tested? <br />es <br />ES <br />H <br />0 <br />ailed precision test ? <br />as <br />of/Year <br />o <br />if <br />yes, give date(Sl) <br />as a repair made to the tank system? as No f yes, what was repaired? <br />-site Well(s> <br />as repair done under inspection? <br />as Roy <br />ere soil samples analyzed? <br />es <br />umber 8 Type <br />)o <br />Irr <br />TXE <br />Pam <br />PH -G <br />ub <br />PH -D <br />Score <br />10 pts <br />if <br />condition <br />is met <br />b/EDB <br />Score S <br />9 pts C <br />if 0 <br />condition R <br />is met E <br />Type of failure/discharge <br />fstance to Well(s) from Tank <br />atastrophic <br />long-term leakage <br />0. Site Feature . Leaching Potential Analysis <br />verfill <br />nknown <br />1 <br />ther: <br />10 <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />soil Samples Received <br />as <br />ES <br />o <br />0 <br />epth to Ground Water <br />/d <br />of/Year <br />verage Annual Precipitation <br />= <br />4 <br />10.25 <br />-site Well(s> <br />es <br />o <br />umber 8 Type <br />I <br />Irr <br />Pam <br />2 /' <br />5- ( ' <br />ub <br />S <br />C <br />0 <br />R <br />E <br />Score <br />10 pts <br />if <br />condition <br />is met <br />s <br />C <br />0 <br />R <br />E <br />Score S <br />9 pts C <br />if 0 <br />condition R <br />is met E <br />Score <br />5 pts <br />if <br />ondition <br />is met <br />fstance to Well(s) from Tank <br />ft; ft; ft - <br />' <br />0. Site Feature . Leaching Potential Analysis <br />inimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />1.100 <br />25-50\1 <br />ractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />resent <br />verage Annual Precipitation (inches) <br />KXXXXX <br /><10 <br />9 <br />10-25 AXXXXXX <br />26.40\2 <br />an -Made conduits which increase vertical migration <br />f leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />resent <br />Inique site features: Recharge area, coarse soil, nearby wells. <br />xxxxx <br />None <br />At least <br />one <br />ore than <br />one <br />COLUMN TOTALS>>>TOTAL POINTS <br />+ <br />ample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />9 pts <br />or more <br />41 <br />48 pts 40 pts or less <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />B <br />1 <br />T <br />50 <br />X <br />50 <br />E <br />50 <br />B <br />.3 <br />T <br />.3 <br />X <br />1. <br />E <br />1. NA\3 <br />Sample Result: <br />TPH <br />ASOLINE <br />AXIMUM ALLOWABLE TPH LEVELS (PPM) <br />IE <br />1000 <br />100 10 <br />10,000 <br />1000 100 <br />OOTNOTES: ***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 />\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 paints. <br />\3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br />2. Recommend Site Closure 1Yas o If Yes, Refer to Site Mitigation for Evaluation <br />V(I. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />CONCUR WITH STAFF <br />RECOMMENDATION FOR CLOSURE <br />ES <br />0 <br />EFERRED TO SITE <br />MITIGATION FOR EVALUATIONES <br />0 <br />ATE REFERRED <br />ATE CLOSURE LETTER MAILED <br />AME OFq <br />.VALUATOR <br />Q, <br />2 /' <br />5- ( ' <br />/ <br />EH 23 80 (UGTWKSHT)\5/90 v <br />EH 29 80 <br />