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SAN JOAQUIN COON UBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH ^TVISION DATE (�� / <br /> 1 UG RKSHEET FOR SITE CLOSURE EVALUATION /S J <br /> SWE-IPS CODE <br /> NAME OF FACILITY Or <br /> TANK 1D # el <br /> ADDRESS /J5-1K _-� W{sGs �rtP S.fv cl CZ1. � P✓N� <br /> TANK SIZE � D FUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit # Facility Status Code �' DOC.SOil/GV Cont Yes No <br /> Number of Tanks at facility <br /> Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 Yes No If yes, give dates) / / <br /> was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done 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 Vater Gip Ref/Year <br /> 9 � Average Annual Precipitation A= 14 10-25 <br /> On-Site Well(s) Yes No Number 8 Type Irr Dom Pub <br /> 5 Score 5 Score Sjio.ili.n <br /> tt; t C 10 pts C 9 pts CODistance to Wells) from Tank ft: O it 0 ifR condition R condition R <br /> V. Site Feature - Leaching Potential AnaLYsisy0 1 E is met Eis met Et <br /> Minimum Depth to groundwater from the Soil Sample (feet) <br /> >100 51-100 S 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> None Unknown Present <br /> <10 9 10-25 xxxxxxx 26-40\2 <br /> Average Annual Precipitation (inches) <br /> XXXXXXMan-Made conduits which increase vertical migration None 4 Unknown Present <br /> of leachate (i.e., septic system, water wells, ponds) / <br /> q At least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None ! one one <br /> COLUMN TOTALS»>TOTAL POINTS 0 + <br /> 3L + s ori <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> u v ISO pp^ B T % E B T % E <br /> Leas s >000 ">PPMAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> GASOLINE 1000 100 10 <br /> Sample Result: <br /> ;�-Uw O G MAXIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL 10,000 1000 100 <br /> -7'?C'TPH D <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not a the teaching 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 points. <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 > ALLowa§ae 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 RELOMMENDAT ION FORCLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90. <br />