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SAN JOAQUIN q- PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA( r [VISION <br /> 1. WORKSHEET FOR SITE CLOSURE EVALUATION <br /> NAME OF FACILITY G YD�_ SWEEPS CODE <br /> ADDRESS c�/G � 4 TANK ID # <br /> TANK SIZE 0� F L TYPE t,y,1e_ . <br /> II. GENERAL SIfE HISTO Y <br /> � *rr <br /> is permit current? Yes No ermit # Facility Status Code Doc.Soil/Gw Coat Yes No j <br /> Number, of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> I 1 I. TANK HISTORY 7� [C 1= / 5 4 c kp 1-74 <br /> Was Tank tested? Yes No Failed precision test 7 YesNo If yes, give date(s)I 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 II TPH-G TPH-D Pb/ED8 <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) J <br /> Soil Samples Received Yes No Depth to Ground Water Vo Ref/Year ��� Average Annual Precipitation A= 14 10-25 <br /> i <br /> On-Site We(l(s) Yes No Number & Type Irr Dam Pub <br /> S Score S Scare S Score <br /> Distance to Well(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts i <br /> 0 if o if 0 if <br /> R condition R condition R condition i <br /> V. Site Feature - Leaching Potential Analysis GlU l3 s E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) 2 71 >100 51-100 S 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> Average Annual Precipitation (inches) xzxxxx <10 9 10-25 xxxxxxx 26-40\2 I <br /> Man-made conduits which increase vertical migratir <br /> of leachate (i.e., septic systems, water t None Unknown Present <br /> Unique site features: R r(e wells. At least More than <br /> [G xxxxxx None 9 one one <br /> L <br /> COLIIM + 3� + Y <br /> Sample Result: (B T X OR E) POINTS 49 pts or more - 48 pts 40 pts or less <br /> B T X E B T X E <br /> LEVELS (PPM) 1 SO 50 5 .3 .3 1. 1. NA\3 ' <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPN LEVELS (PPK) <br /> TPH DIESEL 10,000 loco toQ � <br /> FOOTNOTES: ***If documented soil and/or ground water contamination Is present, da sample the leaching potential <br /> analysis. (i.e., site is currently an UGT Contamination List for 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 BTX&E are not.applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> Vi. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No �;_".�e"L r[n-e o�•tr-c�((�,,,,���� <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation <br /> VII. 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 />