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SAN JOAQUIN CL_ .Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL 11VISION — Q <br />I UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br />SWE'cPS CODE 3 I 0 <br />NAME OF FACILITY L <br />7- <br />ADDRESS <br />/ �, - /1/ (TANK IO :I �i3 - I.D t�7 <br />TANK SIZE 1D (FUEL TYPE iQ <br />11. GENERAL SITE HISTORY **� <br />Is permit current? Yes No' 'Permit 'Facility Status Code Doc.SoiL/GW Cont Yes lNo <br />Number of Tanks at facility J Age of Tanks(if aavailable)I� Type of Tank Steel IFbrgl Sngl' Dual <br />III. TANK HISTOR7 lMS't � 17'77 <br />Was Tank tested? Y�N�OF�aiLedprecision test ? Yes / \ No 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 INo Were soil samples �analyzed? IYes Nal BTXEIITPH-GI <br />Type of failure/dischargecatastrophic long-term leakage (o) '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 ; <br />Average Annual PrecipitationlA=l14 10-25 <br />On-Site Well(S) Yes NoI Number & 7ype' Irrl 'Dom) 'Pub <br />S Score S Score S Score <br />Distance to WeIL(s) from Tank ft; ft; ft C if pts C pts C 5 pts <br />i <br />0 f 0 if 0 if <br />R condition R condition R condition <br />V. Site Feature - Leaching Potential Analysis "t is met E is met E is met <br />LI-0-1 >100 l I51-100 l 125-50\1 <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />Unknown I I (Present <br />Fractures in subsurface (applies to foothills or mountain areas) None j L I l <br />(Average Annual Precipitation (inches) xXXXXXI <10 l 9 l 10-25 Ixxxxxxx' 26-40\2 <br />Man-Made conduits which increase vertical migrations None I I Unknown (Present <br />of leachate (i.e., septic systems, water wells, ponds) <br />At least More than <br />xx <br />Unique site features: Recharge area, coarse soil, nearby wells- X== fore ore one <br />COLUMN TOTALS> >TOTAL POINTS <br />Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br />� <br />4rX Q�. N L <br />'( B T X E B XN`SJMAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 505050I.3 JT <br />.3 11.1 1. NA\3 <br />rt GASOLINE 1000 100 10 <br />Sample Result \4 <br />TPH MAXIMUM ALLOWABLE TPH LEVELS (PPM) 100 <br />DIESEL 10,000 1000 <br />FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not a 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 c=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 />Vt. STAFF RECOMMENDATION/CONCLUSION r;` <br />1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes) No <br />2. Recommend Site ClosureIIel No *if Yes, Refer to Site Mitigatio�flr valuation _S <br />VIi. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE IYES INOI REFERRED TO SITE MITIGATION FOR EVALUATI0NIYE5 INOI <br />DATE REFERRED I DATE CLOSURE LETTER MAILEDI <br />NAME OF <br />EVALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />