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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALIN DIVISION Q <br /> I. "-�T WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY •L✓ u L ;j 4--, — -+!4EPS CODE <br /> ADDRESS 36 fC, 9S TANK ID g <br /> TANK SIZE 13000 FUEL TYPE ri' 'z ,- I „ ^-� cr_. �/ <br /> Il. GENERAL SITE HISTORY /NG-^Y�' U( <br /> Is permit current? Yes No I Oemit C - Facility Status Code Doc.Soil/GW Coni Yes No <br /> Number of Tanks at facility Age of Tanks(if available) V/ Type of Tank Steel Fbr9L Sngl Dual <br /> III. 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 Nol If yes, what was repaired? <br /> Was repair done under impaction? Yes No Were soil samples analyzed] Yes No BTXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic tong-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 Yater f/Year (OAverage Annual Precipitation A= 14 10-25 <br /> On-Site well(s) Yes No Number & Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 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 /> Minirm Depth to groundwater from the Soil Sample (feet) >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or muntain areas) None UnknownPresent <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Mar.-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> COL TOTALS»>TOTAL POINTS + <br /> Sample Result: (8 T X OR E) !( / RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pis or less <br /> B TX E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sanple esult: GASOLINE 7000 100 10 <br /> n(Ja+M M�0(I MUM ALLOWABLE TPH LEVELS (PPM) <br /> N DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not coaplete 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 <br /> 1. Are BTX & E or TPH Concentrations > Allowable 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 RECOMMENDATION FOR CLOSURE YES 11 NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER NAILED <br /> NAME OF <br /> E`lALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />