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SAN JOAQUIN M-TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL,7"-DIVISION --� <br /> I. "T k' FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY EPS CODE Z.,3 Z <br /> "O.5 67fi <br /> ADDRESS r. �, ��� TANK [D <br /> TANK SIZE FUEL TYPE t <br /> II. GENERAL SITE HISMIRY t <br /> Is permit current? Yes No I L4permit # - �j Facility Status Codeqq Doc.S it/Gw Cont Yes Ha <br /> t <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Stee!y <br /> Fbrgl Sngl Due! <br /> III. TANK HISTORY { <br /> Was Tank tested? Yes No Failed precision test ? YesNo If yes, give date(s) / J J J <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 soil samples analyzed? Yes No BTXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH IHS CTION REPORT FOR SITE`DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes VNo Depth to Ground dater JJ Ref/Year I 6f r ; 64 Average Annual Precipitation A= 14 10-25 <br /> On-site NeLL(s) Yes No IANumber & Type Irr Dao Pub <br /> S Score 5 Score 5 Scare <br /> Distance to WeLL(S) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if i <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> ' 1 '100 51-100 25-50\1 <br /> Minimum Depth to groundwater from the Soil Sample (feet)25-1-= J2 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> Average Annual Precipitation (inches) <br /> <10 9 10-25 xxxxxxx 25-40\2 { <br /> Man-Made conduits which increase vertical migration None 1 Unknown Present <br /> of leachate (i.e., septic systems, water wells, ponds) <br /> Unique site features: Recharge area, coarse soil, nearby wells. (] At least More than <br /> xxxxxx None "f one 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 /> B +T = N-D 81 T I X E B T-31 <br /> E <br /> rA ' 2 A" MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 . 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> !j O �yd'1'�H MAXIMUM ALLOWABLE TPH LEVELS (PPM) 1000 100 <br /> '7 F TP DIESEL 10,000 <br /> FOOTNOTES: ***If documented sail 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. m (diesel}. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 pp <br /> i <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > A LfowabLe Levels *Yes No <br /> 2. Recormerd Site Closure Yes No it Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/sPIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO 1 REFERRED TO SITE MITIGATION FOR EVALUATION YES t k1101 <br /> DATE REFERRED / �/ DATE CLOSURE LETTER MAILED <br /> ALIDIfL .a UA��. <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> „ IG <br />