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SAN JOAQUIN CO! PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALT;`":VISION <br /> I, Ii WORKSHEET FOR SITE CLOSURE EVALUATION i DATE 3 C� <br /> NAME OF FACILITY rt?! !7 L�O�N �t� �. 1 SWEEPS CODE �� <br /> wb �, �T Z:7�I /V TANK ID # <br /> ADDRESS <br /> TANK SIZE �j FUEL TYPE � yLr <br /> II. GENERAL SITE HISTORY <br /> *** <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) t`% Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No IKI Failed precision test 7 Yes No I 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/E06 <br /> Type of failure/discharge catastrophic long-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 to Ground Water ' Ref/Year ; Average Annual Precipitation A= 14 10-25 <br /> On-Site Well(s) Yes No Number & Type Irr Dan Il <br /> Pub <br /> S Score S Score S Score <br /> Distance to WeLI(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 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 /> Ilan-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 + �� + =41/ <br /> Safple Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> CID <br /> j0) r7/��'► i:-- B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> I� gel ,V^ 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 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPN Concentrations > Allowable Levels *Yes191 No ✓fJ f <br /> 2. Recommend Site Closure Yes No I x *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 V NO REFERRED TO SITE MITIGATION FOR EVALUATION YES VjNOl <br /> DATE REFERRED / /�2/ 4 DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR ez�, ft o <br /> EH 23 80 (UGTWKSHT)\5/90 _ <br />