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I- SAN JOAQUIN � . 'r\ PU86 C,HEALTH SERVICES/ENVIRONMENTAL HEAT �l7VISION <br /> � _ !WORKSHEEET FOR SITE CLOSURE EVALUATIONr <br /> �, .� DATE <br /> NAME OF FACILITY <br /> WEEPS CODE Y <br /> •ADDRESS lJ� <br /> i v p � TANK ID # - c /6 <br /> (TANK SIZE FUEL TYPE :� v <br /> ; <br /> It. GENERAL SITE HISTORY <br /> Is-permit current? Yes Na Permit <br /> = Facility Status Code Dac.Soil/GW`Cartt Yes No <br /> Number of Tanks at facility ��Age of Tanks(if available) Type of Tank Stee{ Fbrgl Srtgl Dual <br /> II:. TANK HISTORY !' <br /> Was Tank tested? Yes No Failed precision test'? Yes' No If;yes,�give dates) <br /> ;las a repair made to the tank system? Yes No If yes, what was repaired? <br /> iWas repair done under inspection? Yes No Were soil samples anaLyzed? Yes No BTXE TA,H-G I TPH-DPb/EDe <br /> 'Type of failure/discharge catastrophic long-term Leakage overfill unknown other: <br /> IV.S REMOVAL HISTORY (ATTACH INSPECTIO REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) ! <br /> Ik <br /> SoiL Samples Received Yes Na Depth to Gruund-sWater Ref/Tear Average Annual Precipitation A= 14 10-25 <br /> ion-Site Wells} Yes No Number 8 Type Pub <br /> S Score S Score S Score r <br /> Distance to WeLL(s) from Tank ft; ft ft C 10 pts C 9 pts , C 5 pts a . <br /> 0 if 0 if 0 if k <br /> R condition R condition R condition <br /> (V. Site Feature - Leaching Potential Analysis !! E is met E is meta: E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100j. 25-50\t <br /> Fractures in subsurface (applies to foothills or mountain areas) Nana Gl Unknown ��', Present: <br /> •Average Annual Precipitation (inches) 4'i xxxxxx <10 <9 10-25,; xxxxxxx 25-40\2 <br /> a <br /> IMan-Made conduits which increase vertices{ migration <br /> loi leachate (i.e., septic systems, water wells, ponds)' Q' None Unknown Present." <br /> jUnique site features: Recharge area, coarse spit, -nearby weds. At Least More than <br /> # xxxxxx None �.. one one <br /> COLUMN TQTALS»>TOTAL POINTS '" � + 7i7 4- <br /> a I <br /> Sample Result: (B T X OR E) RANGE..0F TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> 3 4,0 -� <br /> 70A 140 a T . X E 6 JT , X-0; <br /> ,7,50 MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 ' 50 50 .3 .3 1. f 1. s, NA\3` <br /> Sample Result: 11 GASOLINE 1000 100 i0 <br /> � MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> (*77 0 0 TPN .p DIESEL 10,000 100) "' 100 <br /> 4./ <br /> FOOTNOTES: ***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, score 0 points. <br /> \3 Levels for STX&E are not applicable at a TAN concentrationof10 ppm (gasoline) or 100 ppm (diese{). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> I. Are BTX 8 E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No If Yes; Refer to Site Mitigation'. for Evaluation <br /> • - ... .:� may'': <br /> VII. REVIEW EVALUATION - TO 9E COMPLETED BY A SUPERVISOR! ENIOR <br /> 6 <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES 11 <br /> NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / �c� / i DATE CLOSURE LETTER MAILEDINAME OF <br /> - u <br /> EVALUATOR r <br /> 2-4 23 80 (UGTWKSHT)\5/90 <br />