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SAN JOAQUIN C^WTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> 1• 'Ohl ST WORKSHEET FOR SITE CLOSURE EVALUATION DATE ���•�/ <br /> NAME OF FACILITY <br /> CL,r,ue /Yl&"tLc-� SWEEPS CODE gS� <br /> ADDRESS lc>� �-� J J/J `��`_ TANK ID # / <br /> TANK SIZE lr7 FUEL TYPE /'G� tw . <br /> 11. GENERAL SITE HISTORY <br /> rrr <br /> Is permit current? Yes No Permit # - Facility Status Code S Doc.soiL/ Cont Yes No <br /> Number of Tanks at facility I Age of Tanks(if available) /X Type of Tank Steeljid�brgll SngL Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 Yes No Ii yes, give date(s) <br /> Was a repair made to the tank system? Yes No f yes, what was repaired? <br /> Was repair done under inspection? as No Were soil samples analyzed? Yes No BTXE TPH-GI TPH-D Pb/EDB <br /> Type of failure/discharge F catastrophic Ilong-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 io Ground Water 1' Ref/Year qs v ; Average AmuaL Precipitation A=114 10-25 <br /> On-Site Welt(s) Yes I V1 <br /> No Number 8 Type Irr 4D Pub <br /> S Score S Score S Score <br /> Distance to Wet I(s) frao Tank /lam 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 /> Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 25-50%1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None 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 systema:, water wells, ponds) None Unknowncj 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 A) + + S <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 1 40 pts or Less <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. 11A\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 9. 9 TPH DIESEL 10,000 1000 / 100 <br /> FOOTNOTES: <br /> If documented soil and/or ground water contamination is present, do not complete the Leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for sail 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, scare 0 points. <br /> \3 Levels for BTX8E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION / <br /> Lewd?_ L(y pPm <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels ryes No <br /> 2. Recommend Site ClosureYes Na 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 /> DATEREFERRED DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />