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SAN JOAQUIN f PUBLIC HEALTH SERVICES/ENVIRONMENTAL H. )IVISION <br /> I' <br /> NAME OF FACILITY CST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> ADDRESS <br /> I�,(( <br /> I �,v V SWEEPS CODE <br /> 2,3 I�3�I ,\ <br /> ��✓ V TANK ID # 1W3_OI (r\p2 0 2- ` 3 <br /> TANK SIZE Zl FUEL TYPE <br /> If. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit # (Facility Status Code DOc.SOil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel ;Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes Nol Failed precision test �yes, <br /> No lif yes, give dates) <br /> Was a repair made to the tank system? Yes No If hatwas repaired? <br /> (Was repair done under inspection? Yes INo Were soil samples analyzed?(Yes No BTXE iTPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophicl hong-term leakage overfill unknown lother: <br /> .V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yesl No Depth to Ground Water Ref/Year �� ;�/_ Average Annual Precipitation <br /> ( A= 14 10-25 <br /> SCJ <br /> On-Site Well(s) Yes No Number & Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to Well(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 Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soit Sample (feet) >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) IO None Unknown I Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> I <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 <br /> one C1 one one <br /> COLUMN TOTALS»>TOTAL POINTS `IF <br /> Sa le Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 48 pts 40 pts or less <br /> al T E a T X <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 11 50 50 50 .3 .3 1. E. <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> L TPH DIESEL 10,000 1000 100 <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 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 100ppm (diesel). <br /> 'Yl. STAFF RECOMMENDATION/CONCLUSION ffil� CA6 L_�✓1 <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No YYYY��M� �6C_E�t � <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Eval T <br /> /it. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/S <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES OI (REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> !DATE REFERRED / DATE CLOSURE LETTER MAILED <br /> 'NAME OF <br /> EVALUATOR <br /> cu 71 nn (11nTUegHT)\9/90 <br />