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SAN lOACUIN CC<RTY�iUBIIC HEALTH SERVICES/E)IVIROHMEHTAL HEALTH :SIGH <br /> 1 UCST VCRZSHEET FCR SITE CLOSURE EVALUATICH <br /> DATE iz/Z0 d y <br /> tt,(� LO"I �C G L S4'E£PS CtAE <br /> �� C C/4 �Gyt - <br /> INAME OF FACILITY TANK IO 2 <br /> jA00RESS <br /> (TANK SIZE FUEL TYPE lj{/yf <br /> rtt <br /> I. GENERAL SITE HISTGRT Status Code D0c•Soil/CJ Cont Yes Ho <br /> Pe it I - Facility <br /> Is per-mit current? Yes N Steel Fbrgl n9 Dtal <br /> HLrber of Tanks at facility <br /> Age of Tanks(if available) ? Type of T <br /> At. TANK HISTORY <br /> recision test 7 Yes No ' <br /> Was Tank tested? Yes No Failed p ` <br /> to=?IYes No <br /> IWas a re^,aIf yes, what was repaired? INl <br /> ir ode to the tank sys Mo Were soil sa ples analyzed? Yes NO 37X- TPN- <br /> Was repair done under ins P"-Cti°n7 Yrs <br /> Type of failure/discharge Catastrophic tom-termlei <br /> overfill ur'rnor.al other: ��lM(J�"� <br /> REb4OVAl HISTORY (ATTACHINSP£CTICU RE?C2T FOR SITE DETAILS/CCLLECT DATA FCR LEACHING POTENTIAL ANALYSIS) <br /> No Depth to Grourd Water Zs Ref/Year 1 <br /> B 9 Average ArrxJal Precipitation A- 14 10-25 <br /> Soil Sarples Receiv Yes <br /> ; <br /> Nor L Type Ire Dae Ptsb Score S Score S Score <br /> Cn-site Well(s) Yes NO S C 9 pts C 5 pts <br /> ft; .!ft C 10 pts 0 if O if <br /> t; if _ - ccrxfiticn <br /> Distance to Wells) from Tank /f R ece-dition R eortidItion R <br /> E is met E is eat <br /> E is net 1. Site Feature - leaching Potentlal Analysis >1O0 51-100 I S Z5-50\1 <br /> afar from the Soil Satple (feet) <br /> IAininm Depth to groin+ Unkno-n Presort <br /> /0 Nxe <br /> Fractures in subsurface (applies to foothills or M aim areas) <t0 9 10-25 25-40\2 <br /> xxxxxx xxxxxxxl <br /> Average Arnual Precipitation (inches) I <br /> N Drys � Urknokn Pre-sent <br /> Nan-Made cerx'uits which increase vertical `93atipoomcds) <br /> of leachate (i.e., septic systecs, At least More than <br /> welts. Cele °Cie <br /> Unique site features: Recharge area, coarse sof 1, nearby xxxxxx Kane <br /> �o (g + <br /> COLI.?W TOTALS),),TOTAL POINTS 41 - 48 pts 40 pts or less I <br /> Roca OF TOTAL POINTS 49 pts or mere I <br /> Sacple Result: (3 T X CR E) E 3 X E7 XALUAIABLE 3-T-X-E LEVELS (PPM) 1 50 50 50 .3 �.T <br /> 3 1. 1. <br /> GASOLINE 1000 <br /> 100 10 <br /> Sartple Result: n 1000 100 <br /> ,A pf,-a MAXIMS ALL(W,HLE TPH LEYELS (P�) DIESEL l0,CC0 <br /> 6 ��� do not complete the leaching potential <br /> documented soil and/or ground water cancaainat{on is present, <br /> _IfFOOTNOTES: amtysis. (i.e., site is currently on UGT Contamination List do Mt usertable- water.) <br /> ft., score 0 points. If depth «5 ft., <br /> \1 If depth is > 5 ft. and < 25 <br /> \2 if precipitation is > 40 inches, score 0 points. (gasoline) or 100 ppm (diesel). <br /> \3 Levels for 3=- are not applicable at a TPH coax entration of 10 ppm <br /> VI. STAFF RECCs44EX0ATIC:w/CONCLUSICX <br /> 1. Are BTX b £ or 7PH Cotxcntratiors > Allowable Levels 'Yes NO <br /> 2. Recomaend Site Closure Yes ° <br /> If Yes, Refer to Site Mitigation for Evaluation <br /> Vtt. REVIEW EVALWTICN - TO 3E COMPLETE-. 3Y A SUPEZVISC2/SENICR I <br /> CCNCJR WITH STAFF RECCm44ENDATICti FCR CLCSISRE YESI NO REFERRED TO SITE MITIGATION FOR EVALWTIGi YES N0 <br /> / DATE CLOSURE LETTER MAILED <br /> - DATE REFERRED / <br /> NAME OF <br /> EVALUATCR <br /> EH Z3 30 (UGTVKSHT)\5/90 <br />