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SAN JOAQUIN CO! PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALT' "'VISION <br /> 1. WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY i�(J �`� �U� 7`, ±,.� _ SWEEPS CODE 04 <br /> ADDRESS l'& �, �[./�-.-/��� TANK ID # 'Z5' -Zcl��.-(j <br /> TANK SIZE 6200 1 FUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit # - Facility Status Code �/� Doc.Soil/GW Con[ Yes No <br /> Number of Tanks at facility Age of Tanks(if available) V.K. Type of Tank Steel Fbrgl Sngl Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 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 done under inspecti on7 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 j Ref/Year ' Average Arcual Precipitation A= 14 10-25 <br /> On-Site Wells) Yes No Number & Type Irr Dom Pub <br /> JR Score S Score S Score <br /> Distance to Wells) from Tank ft; ft; it 10 pts C 9 pts C 5 pts <br /> if 0 if 0 if <br /> condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 b.2 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> Average Annual Precipitation (inches) <10 9 10-25 xxxxxxx 26-40\2 <br /> Ilan-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, Water wells, ponds) None Unknown Present <br /> Uiique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> None one one <br /> COLUMN TOTALS>»TOTAL POINTS <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> IT- aopprl Z{To�r-? <br /> != $Nall/ 'l B T X E B T I X E <br /> i�u d'jj'%j MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> �Od� 1 n, TPH' DIESEL 10,000 1000 100 <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 /> \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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION /per � -itJ <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No V/`v <br /> om nd Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation <br /> VIE. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES VINCI REFERRED TO SITE MITIGATION FOR EVALUATION YES VjNOj <br /> DATE REFERRED �L / '2, DATE CLOSURE LETTER MAILED / / <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />