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SAN JOAQUIN ( Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA )(VISION <br /> I• ...,ST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> ;AME OF OF FACILITYS'�/Sr/� �a�U,nj� %la� WEEPS CODE <br /> DDRESS ! (f .? (�� ./� N c' / CT C /7 Cid 4�� TANK to a 3y ,G7 <br /> IANK SIZE / d�` IF <br /> UEL TYPE l)Q S t '4Y <br /> II. GENERAL SITE HISTd)`RY <br /> Is permit current? es o i/ ermit a - acitity Status Code C� oc.Soil/GW Cont es o <br /> umber of Tanks at facility Y' ge of Tanks(if available) ype of Tank teel Fbrgl ngl Dual <br /> Ill. TANK HISTORY <br /> as Tank tested? If <br /> es I IN <br /> o y', ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? Yes No 1 11f yes, what was repaired? <br /> as repair done urxier inspection? es 40 dere soil samples analyzed? es 14o TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill I nknown I locher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes o epth to Ground Water r_f,) of/Tear , ; verage Annual Precipitation = 4 0 25 <br /> i-Site Welt(s) 1Y <br /> es o umber 8 Type Irr om ub <br /> S Score S Score S Score <br /> istance 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 ondition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimun Depth to groundwater from the Soil Sample (feet) / << - >100 1-100 j 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown Dresent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None y Unknown >resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS t ( + "l 1f + (— <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS ,9 pts or more 41 48 pts 40 pts or less <br /> xY B T XTE8 T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 505 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> 4)if s AXIMUH ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 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 BTXBE are not applicable at a TPN concentration of 10 pprn (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION n —`" f .( O 47, <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yeso �� /I, <br /> 2. Recommend Site Closure es o 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 0 EFERRED TO SITE MITIGATION FOR EVALUATION YES 0 <br /> )ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> 1AHE OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />