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SAN JOAQUIN PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE VISION DATE <br /> /� ,GST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> NAME OF FACILITY 1p7 �, 9 - S EPS COOEI p� 3 <br /> „ T K ID =I <br /> AOORESS17 / - 4Z� �l <br /> FUEL TYPE <br /> TANK SIZE F l <br /> I . GENERAL SITE HISTORY <br /> EHEcurrent? les lNo Permit # - Facility Status Cade g Daa..SoiL/GW Cant Yes No <br /> Number of Tanks at facility <br /> Age of Tanks( if available) 6Uw4IType of Tank Steell Fbrgl Sngl Dual <br /> , II . TANK HISTORY <br /> Was Tank tested? Yes lNa Failed precision test ? Yes No if yes , give dates ) <br /> Was a repair made to Che tank system? Yes No lIf yes , what was repaired? <br /> iWas repair done under inspection? ( Yes INaI I <br /> Were soil samples analyzed? Yes No BTXEI ITPH-G ITPH-D lPb/EDN <br /> ( Type of failure discharge catastrophic ) long' term leakage overfill unknown lather: <br /> IV . REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Yesl NO , Depth to Ground Water Ref/Year , <br /> Average Annual Precipitation ) A= 14 10- 25 <br /> Soil Samples Received <br /> an- Bice Wells ) Yes No ( Number & Type Irr Don Pub <br /> S Scare S Scare S Scare <br /> Distance to WeLL ( s ) frau Tank ft ; ft ; ft C 10 pts C 9 Pts a Sfpts <br /> O if 0 if <br /> R condition R condition R condi <br /> Cion <br /> is met E is met E s <br /> V . Site Feature - Leaching Potential Analysis I <br /> Minimum Depth to groundwater from the Soil Sample ( feet ) <br /> I >mo I ist - too I zs - 5av <br /> Fractures in subsurface ( applies to foothills or mountain areas ) <br /> l None i I Unknown l ( Present <br /> <10 9 t0- Z5 xxxxxxxl 26- 40\Z <br /> Average Annual Precipitation ( inches ) <br /> xxxxxx I I l <br /> Man-Made conduits which increase vertical migration I None I I Unknown ( Present <br /> of Leachate ( i . e . , septic systems , water wells + ponds ) <br /> At least More than <br /> ( Unique site features : Recharge area , coarse sail , nearby wells . one one <br /> xxxxxx More <br /> mI � I <br /> COLUMN TOTALS»>TOTAL POINTS <br /> 5amole Re lt : ( B T X OR E) RANGE. OF TOTAL POINTS 49 pts or more i 41 - 4a pts 40 pts or less <br /> tiU .D cS P L.lj U I Y � .htT7�. & 3 a T X B T X l E <br /> _ NA\3 <br /> 11 5 L' MAXIMUM ALLOWABLE S-T-X-E LEVELS (PPM) 1 50 SOI 50 I .3 .3 11 . E i . <br /> • ' �y IN 1000 l 100 10 <br /> GASOL <br /> W Sample Result : f t rPN l l <br /> �MAXImuM ALLOWABLE TPH LEVELS (PPM) 000 1G0O 100 <br /> M) DIESEL 10, <br /> rpx TPI + =5(0 <br /> FOOTNOTES : <br /> **' If documented soil and/or ground water contamination is present , do not complete she leaching potential <br /> analysis . ( i . e. , site i5 current Ly an UGT Contamination List for sail or ground water . <br /> \1 If depth is > 5 ft. and < 25 ft . , score 0 points. if depth r-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 t0 ppm (gaassolin(e)) or 1DO Fill (diesel ) - e <br /> Vi . STAFF RECOMMENDATION/CONCLUSION /CSG { \ <br /> �c3- 1G11-.�- C7 <br /> 1 . Are BTX & E or TPH Concentrations > Allowable levels 'Yell No •�/UC'JL <br /> 2 . Recommend Sire Closure Yesl Na �•If Yes , Refer to Site Mitigation for Eva Luation <br /> VII , REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIORMilli <br /> CAlllllll�l MEN IN llllllllllllll4l III ONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYI IMO IREFERRED TO SITE MITIGATION FOR EVALWT10N <br /> iYE5 NOI <br /> DATE CLOSURE LETTER MAILED <br /> DATE REFERRED / <br /> NAME OF ` Q <br /> EVALUATOR <br /> EH 23 80 (UGjWKSHT ) \5/90 <br />