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1. <br />NAME OF FACILITY <br />ADDRESS 2 Ll <br />3 TANK SIZE <br />11. GENERALS E H <br />SAN JOAQUINC PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA&VISION <br />u'ST WORKSHEET FOR SITE CLOSURE EVALUATION DATEFf ( <br />C�&I-1/A0 T t- -P" =SWEEPS CODE <br />I'.I S �� ( 5 4V&e TANK 10 # � S=t S -6p <br />1. <br />FUEL TYPE <br />O <br />i permit current? Yes IRINo Permit # - Facility Status Code Doc.Soi L/GW Cont Yes No <br />tuber of Tanks at facility 3 Age of Tanks(if available) V&aC Type of Tan Steel Fbrgl 5ngl Dual <br />III. TANK HISTORI <br />Was Tank tested? <br />Yes <br />x <br />No <br />%C <br />Failed precision test ? <br />Ye,7 <br />Ref/Year <br />No <br />If <br />yes, give date(s) <br />I 14 <br />Was a repair made to the tank system? <br />Yes <br />No <br />1C <br />If yes, what: was repaired? <br />Was repair done under inspection? <br />Yes <br />Irr <br />No <br />Dom <br />Were soil samples analyzed? <br />Yes <br />S <br />C <br />0 - <br />R <br />E <br />No <br />S <br />C <br />0 <br />R <br />E <br />BTXE <br />S <br />C <br />0 <br />R <br />E <br />TPH-GTPH-D <br />Distance to Wet l(s) from Tank <br />ft; ft; - ft <br />Pb/EDB <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />Type of failure/discharge <br />>100 <br />catastrophic <br />51-100 <br />long-term Leakage <br />25-50\1 <br />overfill <br />unknown <br />other: <br />:V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />G <br />Soil Samples Received Yes <br />YES <br />x <br />No <br />Depth to Ground Water <br />YES <br />Ref/Year <br />NO <br />Average Annual Precipitation <br />A= <br />I 14 <br />10-25 <br />On -Site Wells) <br />Yes <br />No <br />Number 8 Type <br />Irr <br />Dom <br />Pub <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 <br />9 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />5 pts <br />if <br />condition <br />is met <br />Distance to Wet l(s) from Tank <br />ft; ft; - ft <br />V. Site Feature - Leaching Potential Analysis .. <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />51-100 <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />Present <br />Average Annual Precipitation (inches) <br />xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />Present <br />Unique site features: Recharge area, coarse soil, nearby welts. <br />xxxxxx <br />None <br />At least <br />one <br />More than <br />one <br />COLUMN TOTALS»>TOTAL POINTS <br />+ <br />+ <br />- <br />Sample Result: (B T % OR E) <br />rI <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />.41 - 48 pts <br />40 pis or Less <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />B <br />1 <br />T <br />50 <br />%E <br />50 <br />50 <br />B <br />.3 <br />T <br />.3 <br />X <br />1. <br />E <br />1. <br />NA\3 <br />(Sample Result; <br />ul <br />N TPH <br />GASOLINE <br />MAXIMGM ALLOWABLE TPH LEVELS (PPM) <br />DIESEL <br />1000 - <br />100 <br />10 <br />10,000 <br />1000 <br />100 <br />FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching potential <br />QP,Ii c II0M3145• 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 />'i- PU/NP \2 If precipitation is > 40 inches, score 0 points. <br />2 n% r \3 Levels for BTXBE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />. STAFF RECOMMENDATION/CONCLUSION E-rL C �-ir L UYb - L11- P3 F L- <br />1. Are BTX 8 E or TPH Concentrations > Allowable Levels *Yes No x <br />2. Recommend Site Closure Yes k <br />No *If Yes, Refer to Site Mitigation for Evaluatiof <br />c <br />I. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />CONCUR,eITH STAFF RECOMMENDATION FOR CLOSURE <br />YES <br />NO <br />REFERRED TO SITE MITIGATION FOR EVALUATION <br />YES <br />NO <br />DATE REFERRED <br />/ / <br />DATE CLOSURE LETTER MAILED <br />/ / <br />NAME OF <br />EVALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />