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SAN JQAOUIN '14TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HI 'Tw DIVISION <br />I ST WORKSHEET FOR SITE CLOSURE EVALUATION DATE 7, 7 <br />NAME OF FACILITY ��ie%+!/ �f�✓ SWEEPS CODE <br />171f7 <br />Zi_ _ _ ., 4._n ITANK ID $ <br />LANK SIZE((FUEL TYPEIQ � <br />S <br />11. GENERAL SITE HISTORY <br />Is permit current? Yes No Permit ft - Facility Status Code Doc,Soi l/GW Cont Yes Na <br />Hunter of Tanks at facility Age of Tanks(if available)( ✓ K Type of Tank Steel Fbrgl Sngt Dual <br />LII. TANK HISTORY <br />Was Tank tested? <br />Yes <br />�'-' <br />No <br />Failed Precision test ? <br />Yes <br />Ref /Yea <br />No <br />Average Annual Precipitation <br />If yes, give date(s) <br />10-25 <br />Was a repair made to the tank system? Yes No <br />if yes, what was repaired? <br />Was repair done under inspection? <br />Yes NoI Were soil samples am lyzed7 Yes <br />Number & Type <br />NoDTXE <br />TPH-G <br />TPH-O Pb/EDB <br />Type of failure/discharge <br />catastrophic Long-term leakage <br />loverfiLL <br />unknown <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received Yes <br />�'-' <br />No <br />Depth to Ground Water <br />K <br />Ref /Yea <br />86 ; 9,Y <br />Average Annual Precipitation <br />A=114 <br />10-25 <br />On -Site Wells) Yes <br />X <br />No <br />Number & Type <br />I <br />Irr <br />Dom <br />Pub <br />S <br />Scare <br />S <br />Score <br />S <br />Score <br />Distance to Well(S) from Tank <br />^ Le ft; ft; ft <br />C <br />10 Pts <br />C <br />9 pts <br />C <br />5 pts <br />0 <br />R <br />if <br />condition <br />0 <br />R <br />if <br />condition <br />0 <br />R <br />if <br />condition <br />V, Site Feature - Leaching Potential Analysis <br />E <br />is met <br />E <br />is met <br />E <br />is met <br />(Minimum Depth to groundwater from the Soil Sample (feet) Zp <br />>100I <br />51-100 <br />O <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />I None <br />I <br />Unknown <br />I <br />(Present <br />Average Annual Precipitation (inches) <br />zzz <br />I <10 <br />I 9 110-25 <br />xxzxxxal <br />26-40\2 <br />Nan -Made conduits which increase vertical migration <br />of leachate (i.e„ septic systems, water wells, ponds) <br />None <br />Unknown <br />S <br />Present <br />site features: Recharge area, coarse soil, nearby wells. <br />At least <br />More than <br />(Unique <br />xxxx>a <br />None <br />one <br />one <br />COLUMN TOTALS>>>TOTAL POINTS <br />2 7 <br />5 <br />= 3 Z <br />Sample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />41 - 48 pts <br />0 pts or less <br />B055' <br />'Al��.oty//� <br />8 <br />X E <br />B T <br />X E <br />=. H5 f/w <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />1 STC, <br />50 50 <br />.3 .3 <br />i, 1. <br />NA\3 <br />'Sample Result:__ <br />'ni/i'(T <br />GASOLINE <br />MAXIMUM ALLOWA8IE <br />1000 I <br />100 ( <br />10 <br />fib, y nodR� <br />TPH LEVELS (PPM) <br />TPH-DDIESEL <br />10,000 <br />1000 <br />100 <br />'FOOTNOTES: —If documented soil and/or ground water contamination is present, do not complete the teaching potential <br />analysis. (i.e., site is currently an UGT Contamination List for soil or ground water.) <br />\1 If depth is > 5 ft. and < 25 ft., score 0 points- If depth (i ft., do not use table. <br />\2 If precipitation is > 40 inches, score 0 points. <br />\3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes 1XINo <br />2. Recommend Site Closure Yes No X If Yes, Refer to Site Mitigation for <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NOI REFERRED TO SITE MITIGATION FOR EVALUATION YES (Hal <br />DATE REFERRED( / / (DATE CLOSURE LETTER MAILED <br />NAME OF <br />EVALUATOR <br />EN Z3 80 (UGTWKSHT)\5/90 <br />