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SAN JOACUIN CaX` VBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH : ON <br /> 4 RXSHEET FOR SITE CLOSURE EVALUATION f DATE <br /> SUt-eS CODE l �G <br /> 5 Q , -4 TANK 10 ! 12' <br /> D C� FUEL TYPE <br /> IT I d C 3 <br /> t current? Yes No Permit S �,/ v d Facility Status Code 0 r Doe.Soil/GV Conc Yes b <br /> mer of Tanks at facility 3 Age of Tanks(If available) �,���� Type of Tank Stell Fbrgl Sr+QI oual -� <br /> i1. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 Yes No X I <br /> If yes, give date(s) <br /> Was a repair made to the tank system? Yes No x If yes, what was repaired? <br /> Was repair done under inspection? Yes No � �' ere soil samples analyzed? Yes No 13TXE I TPH-G TPH-0 Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br />:V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water Litz Ref/Year �-b ; Average Annual Precipitation A= t4 10-25 <br /> On-Site Wells) YesNo Number L Type Irr �( Dom Pub <br /> S Score S Score S Score <br /> Distance to Wells) from Tank 3 EC 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 net E is met <br /> Minimum Oepth to groundwater from the Soil Sample (feet) >100 51-100 5 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 /> I lade conduits which increase vertical migration Present <br /> o?—Leachate (i.e., septic systems, water wells, ponds) None ` oma <br /> Unique site features: Recharge area, coarse soil, nearby wells. �y At least More than <br /> xxxxxx None / one one <br /> COLUMN TOTALS»),TOTAL POINTS JD } L/ S Z_ <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> y" S � BT X E B T X E <br /> . � <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> £ MAXIMUM ALLOWABLE TPH LEVELS (PPM) 100 <br /> TPH-d DIESEL 10,000 1000 <br /> FOOTNOTES: "'If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (1.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 STX&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX L E or TPN Concentrations > Allowable Levels 'Yes No <br /> 2. Recommend Site Closure Yes No 'If Yes, Refer to Site Mitigation for Evaluation <br />' VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUP£RVISOR/SENIOR <br /> CONCU(t <br /> WITH STAFF RECCl41ENDATION FOR CLOSURE YES 0 REFERRED TO SITE MITIGATION FOR EVALUATION YES <br /> AIE REFERRED Q / / DATE CLOSURE LETTER MAILED / / <br /> 4 NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />