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SAN JOAQUIN WATT PUBLIC HEALTH SERVICES/EMVIRONMENTAL HEALTH DIVISION <br /> 1' UGC 'ORICSKEET FOR SITE CLOSURE EVALUATION GATE <br /> NAME OF FACILITY <br /> 3 CODE <br /> IT <br /> TAIMI tD MSIZE FUEL TYPE /_e <br /> It. DEMERAL SITE HISTORY <br /> Is permit currentT Yes No Permtit of - Facility Status Code Doc.Soil/GW cont Yes No <br /> Number of Tanks at facitfty Age of Tanks(if aveitable) Type of Tank Steel Fbrpl Shpt Dual <br /> Ill. TANK HISTORY <br /> Was Tank tested? Yes Mo Failed precision test ? Yes Mo If yrs, give dote(s) <br /> Was a repair mode to the tank systew Yea no If yes, what was repairsdT <br /> Was repair done under inspection? Yp No Ware soil samples anetyzedt Yes Mo BTXE TPM•G 711.0 Pb/ED8 <br /> Type of faiture/discharge catastrophic tong-tem teakapa overfill unknown other: <br /> IV. REMOVAL NISTORT (ATTACK INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soft Saaptes Received Yes No Depth to Ground Water naf/Year Average Annul Precipitation M 14 10-25 <br /> On-Site Welts) Yes No Number i Type irr Das Pub <br /> S Score S Score S score <br /> Distance to Wett(s) 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 Analysts E is meet E is met E is met <br /> Minimen Depth to groundwater from the Soft Sample (feet) oz r <br /> 30100 51-100 25•50\1 <br /> Fractures in subsurface (applfes to foothills or mountain areas) Name Unknown Present <br /> Average Annual Precipitation Cfnehes) xoOo= 410 9 10-25 xrono= 26-40\2 <br /> Jqn-Made Conduits which inerease vertical migration <br /> Of teachate Ci.e., septic systems, water walls, panda) Kone Unknown '� Present <br /> Unique site features: Recharge area, coarse soft, nearby walls. At least Nore than <br /> xotm= now ane one <br /> COLUMN TOTALS),»TOTAL POINTS + + : <br /> Sm1e Result: CS T X OR E) um OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> y- �r B T I X I E S IT I X E <br /> NAXIMUN ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. MA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> AI,A, • �Lld TPN-6_ MAXI" ALLOWALE TPM LEVELS (PPM) 0113ft I 10,000 1000 too <br /> FOOTMOTES: —If documented soil and/or grand water caetasinetion is present, do not Complete the leaching potential <br /> analysis. Cf.e., sits is Currently on UGT Contamination list for soil or ground water.) <br /> \1 If depth Is > S ft. and < 25 ft., score 0 points. If depth aS ft., do not use table. <br /> \2 If precipitation is > 40 1 A a. score 0 points. <br /> \3 Lewis for BT301 an not applicable at a TPR concentration of 10 ppm Cgssoline) or 100 ppm (dfesel). <br /> VI. STAFF RECO NDWATION/CONCLUSION G 6A-0 1/'Y"I <br /> 1. Are BTX & E or TPN Concentrations > Allowable levels 'Yes NO <br /> 2. Recommend Site ClosureYea No If Yes, Refer to Site Mitigation for Evaluation <br /> II <br /> Vit. REVIEW EVALUATION - TO BE COMPLET® SY A SUPERVISOR/SENIOR <br /> COMMIR WITH STAFF RECOM MRIATIOM FOR CLOSURE YES MO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> ATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EN Z3 80 (UGTUACSNT)\5/90 l <br /> � goLt� a«i! 5 nI�•�N <br />