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SAN JOAQUIN COIJPUBLIC HEALTH SERVICES/ENYiRONMEHTAL HEAL> tY1SlON DATE f(� ^�� <br /> IM <br /> WORKSHEET FOR SITE CLOSURE EVALUATION <br /> � WEEPS CODE <br /> NAME OF FAClLlTY K v <br /> ADDRESS TANK ld 3 q - l 5$I Y D <br /> 3,O O 3 c <br /> ��1 FUEL TYPE <br /> Di <br /> TANK 512E W[� <br /> °I: <br /> Ii. GENERAL SITE HISTORY *** <br /> I Is permit current? Yes Y No Permit - Facility Ststua Code oc.5oil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(If available) Type of Tank Steel Fhrgt Sngl Duel <br /> . III. TANK HISTORY <br /> was Tank tested? �tothe <br /> �tank <br /> Failed precision Lest ? Yes No If yes, give dates) f.? / J /��. <br /> was a repair madeystem? Yes No if yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-0 TPH-1 Pb/EDB <br /> 1 Type of failure/discharge catastrophic tong-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 WajDo <br /> Ref/Year Average Annual Precipitation A= 14 10-25 <br /> p <br /> On-Site Wet (s) Yes No Humber & Type Irrm Pub ;. <br /> S Score S Score S Score <br /> Distance to WellIf <br /> s) froia Tank ft; ft; ft C pts C I pts "C 5 pts <br /> 11. o f o 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 /> r <br /> Minimum Depth to groundwater from the Soft Semple (feet) ,��=L{ >1Q0 51-100 25-54\1 <br />{ Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> Average Anal Precipitation (Inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> nu <br /> Man-Made conduits which increase vertical migration Present <br /> ` of leachate (i.e., septic systems, water wells, ponds) None Unknown <br /> + Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> 1 xxxxxx None one � one <br /> COLUMN TOTALS»>TOTAL POINTS f IS 1 <br /> Sampte Result: (8 T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts Aar <br /> (3 - 0,4047 T= .070 B TX E B T X E <br /> X= !+D = D.3�- MAXIMUM ALLOWABLE B'T-X-E LEVEES (PPM) 1 5D 5D 50 .3 .3 1. i NA\3 <br /> Sample Result: T H3 GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> & PH-0 DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented salt and/or ground water contamination is present, do not complete the leaching potent a <br /> '1 analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> i \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. <br /> 1. Are 8TX & E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site ClosureYes No <br /> If Yes, Refer to Sit* Mitigation for Evaluation <br /> u <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF REC"ENDATION FOR CLOSURE YE5 LfNOj REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED l 2/ 3 O / y S DATE CLOSURE LETTER MAILED <br /> NAME OF 3 Q �y�e--.•-� <br /> EVALUATOR I <br /> EN 23 80 (UGTWKSHT)\5/90 _ <br /> l <br />