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SAN JOAQUIN �TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEO DIVISION <br /> t• ST WORKSHEET FOR SITE CLOSURE EVALUATION DATE Z 2-(O cr <br /> NAME OF FACILITY G R-S ISWEEPS CODE <br /> ADDRESS 'rj KO C-1 Y-0 tA+ Cjc� TANK ID it - <br /> TANK S12E FUEL TYPE r <br /> II. GENERAL SITE HISTORY EivYl" �}SSGsssu�v�m <br /> e** <br /> Is permit current? Yes No Permit q - Facility Status Code Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(it available) Tank Steel Fbrgl Sngt Dual <br /> III. TANK HISTORY - <br /> Was Tank tested? Yes No Failed prec' test ? Yes No If yes, give date(s) <br /> Was a repair made to the tank s '� Yes No If yes, what was repaired? <br /> Was repair done and nspection7 Yes No Were soil samples analyzed? Yes No 6TXE TPH-G TPH-D Pb/EDB <br /> Type of ure/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 3SI Ref/Year Average Annual Precipitation I <br /> On-Site Wetl(s) Yes No Number 8 Type Irr Dom Pub <br /> S Score S Score S <br /> Distance to Wetl(s) from Tank ft; ft; ft C 10 pts C 9 pts C <br /> 0 if 0 if 0 R condition R condition R V. Site Feature - Leaching Potential Analysis E is met E is met E <br /> Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 S 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) I O None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <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 /> xmmx None 92 one one <br /> COLUMN TOTALS»>TOTAL POINTS V + Z 7 + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T % E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. NA\3 <br /> Sample Resutt: t'9-PPn. GASOLINE 1000 100 10 <br /> ?� MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 2 10 TPH AO DIESEL 10,000 1000 100 <br /> ,FOOTNOTES: **If documented soil and/or ground water contamination is present, do not comp ate 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 TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> . STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation - <br /> 1. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR,.WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />