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SAN JOAQUINrATY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H DIVISION G <br /> I UGST WORKSHEET FOR SITE CLOSURE EYALUATIvI, DATE <br /> NAME OF FACILITY SfD G{L°�DS�eC!iC� SWEEPS CODE 1 '� <br /> ADDRESS 403 /� J_ TANK iD !! 5,SI— <br /> TANK SIZE ?3 00C> FUEL TYPE <br /> I <br /> II. GEHERAL SITE HISTORY <br /> wr* <br /> Is permit current? Yes No Permit 0 3 - Facility Status Code Doe.Solt/GW Cant Yea No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgt Sngl Duel <br /> Ill. TANK HISTORY <br /> Was Tank tested? Yes No Felled precision test 7 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 No Were salt samples analyzed? Yes No BTXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfiil I unknown I 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 Q Ref/Year Average Annual Precipitation A■ 14 10-25 <br /> On-Site Welts) YesNo Number b Type=_-, <br /> ype Irr Dom Pub <br /> S Score S Score 5 Score <br /> Distance to Wells) froia Tank ft; ft; ft C 10 pts C 9 pts :I 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)6 —/& Z"N >100 51-100• 25-50\i <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 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic system, water wells, ponds) None Unknown. Present <br /> Unique site features: Recharge area, coarse soil, nearby Nelle. At least More than <br /> xxxxxx None one 5 one <br /> COLUMN TOTALS—,TOTAL POINTS + + l✓ e <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> �( I A) B T X E B IT 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 j' 10 <br /> I�N MAXIMUN ALLOWABLE TPH LEVELS (PPM)V TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground voter contamination 1s present, do not comptete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soft 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 j- 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 # a 3 S tc,&---J <br /> 1. Are BTX A E or TPH Concentrations > Allowable Levels "Yes No a--r�a�6'evui <br /> 2. Recommend Site Closure Yes Ho *If Yes, War to Site MitlBatlon for Evaluation <br /> E VI1. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR � <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURETES NO REFERRED TO SITE MITIGATION FOR EY DATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER NAILED <br /> NAME OF <br /> EVALUATOR "L! �.�'l/✓ 'i <br /> EH 23 80 .CUGTWKSHT)\5/90 <br /> k <br /> i <br /> I <br />