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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH �SION DATE 7 - 3) / — C�' <br /> l UGS `RKSHEET FOR SITE CLOSURE EVALUATION <br /> S;,,,zPS CODE <br /> NAME OF FACILITY L'L//1?/f^�'I C„ q' _ <br /> iADDRESS <br /> TANK SIZEC) FUEL TYPE .. , <br /> "" U <br /> It. GENERAL SITE HISTORY ':� <br /> is permit cur rend Yes No Permit tl <br /> Facty Status Code 5i Doc.Soil/GV Cont Yes No <br /> Nuiber of Tanks at facility Age of Tanks(if available) ki.tType of lank Steel Fbrgl Sngl Dual <br /> Ill. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 Yes No It yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> was repair done aider inspection? Yes No were soil samples are Lyzed? Yes No BTXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic Long-term leakage overfill1 1.nknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Sail Samples Received Yes No Depth to Ground Water Ref/Year <br /> Average Annual Precipitation A• 14 10-25 <br /> on-Site WeLl(s) Yes No Number L Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to We(l(s) from Tank ft; ft; ft C 1 0 pts 0 pts if0 pts <br /> 0 it if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sade (feet) <br /> >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> No Unknown Present <br /> Average Annual Precipitation (inches) <br /> XXxxxX <10 9 10-25 xxxxxxx 26-40\2 <br /> Nan-Made conduits which increase vertical migration Nona Upon Present <br /> of leachate (i.e., septic systems, water wells, ponds) <br /> At least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. XXXXXX NOna one one <br /> COLUMN TOTALS»>TOTAL POINTS + <br /> Sag1Le Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 4a pts 40 pts or Less <br /> Aft <br /> Ab' +"� a T X E a T X E <br /> /'t MAXI" ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> GASOLINE 1000 100 10 <br /> Samplc Result: <br /> MAXI" ALLOWABLE TPR LEVELS (PPM) DIESEL 10,000 1000 100 <br /> rpx <br /> FOOTNOTES: " If documented colt and/or grand water contamination is present, do not conplete the leeching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or grand water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth v5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for aTXBE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION J.� <br /> 1. Are BLsTX E E or TPN Concentrations > Allowable Leve 'Yes No i/Y' <br /> 2. Recomnerd Site Closure Yes 1KNo It Yea, Refer to Site Nitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CCNC.'R WITH STAFF RECOMMENDATION FCR CLOSURE YES No REFERRED TO SITE MITIGATION FOR EVALUATION YES �� NO <br /> DATE REFERR1:0 / / DATE CLOSURE <br /> �LETTER <br /> -MAIL/ED <br /> NAME OF <br /> Jv "vl <br /> EVALUATOR <br /> EH 23 30 (UGT'JKSHT)\5/90 <br />