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SAN JOAQUIN CG"MTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION / <br /> I. 4 iT WORKSHEET FOR SITE CLOSURE EVALUATION DATE / <br /> NAME OF FACILITY 5 �'� a,,ILL4 SWEEPS CODE <br /> ADDRESS r,jY �-� yW - TANK ID # <br /> 39 massa -v / <br /> TANK SIZE 0p Qc<C FUEL TYPE LG<esuL <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Yes No Vfp,rmit # - Facility Status Code Sot Doc.Soi l/GW Cont as= <br /> i <br /> Number of Tanks at facility Age of Tanks(if available) VA_ Type of Tank Steel I TFbrgtl ISnal Dual <br /> 11I. TANK HISTORY <br /> Was Tank tested? Yes No yrFaiLed precision test 7 Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? 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 Y No Depth to Ground Water Id-o' Ret/,Year I IY$b; Average Annual Precipitation A= 14 10-25 <br /> On-Site Wells) Yes No Number & Type Irr Dom I VrPub <br /> S Score S Score S Score <br /> Distance to Wells) from Tank IIS ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if O 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 /> Minimum Depth to groundwater from the Soil Sample (feet) I _ IC >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Q Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-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 /> COLUMN TOTALS»>TOTAL POINTS I GI <br /> + d--7 I <br /> + S = 4 <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> � = 35 <br /> m = 7.3 B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 5 .3 .3 1. 1. 1 NA\3 <br /> Sample Result: GASOLINE 1000 100 / 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> LO SL�O TPH—G DIESEL 10,000 1000_ 100 <br /> FOOTNOTES: •*•If documented soil and/or ground water contamination is present, do not canp�et 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 L Q 0.c( z 60 PP"L <br /> 1. Are BTX & E or TPH Concentrations > ALIle Levels *Yes No <br /> - EW� = aao �PM <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 NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / '2/ DATE CLOSURE LETTER.MAILED <br /> NAME OF <br /> EVALUATOR <br /> EN 23 80 (UGTWKSHT)\5/90 <br />