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usT <br /> SAN .lOAOUIN r' '! PUBLIC HEALTH S'cRVICES/ENVIROMXENTAL HE ' ) [VISION 3 oo <br /> [ . .4T WORKSHEET FOR SITE CLOSURE EVALUATION DATE (-O23/Q ::q <br /> [ NAME OF FACILITY <br /> if- S1-Gv- S CODE <br /> IADDRESS t '�4.5 N Corral CSU ( OL.L) ( TANK ID k13 _L(� <br /> TANK SIZEI - IFUEL TYPE <br /> ff . GENERAL SITE HISTORY <br /> Is permit current? [ Yes No Permit ? - ( Facility Status CodelS 2 IDac . Sail /GW CantlYesl � NoI <br /> [ Number of Tanks at faciLityl fa [ Age of ranks( if available ) [ Unk ( Type of TanklSteellxlFbrgL Sngtl Dual <br /> fit , TANK HISTORY <br /> Vas rank tested7IYes No x Failed precision test ? Yesl No If yes , give date( s ) I <br /> Was a repair made cc the rank system? Yes NaI Itf yes , what was repaired? l <br /> Was repair done under inspection? [ Yes Nol �1 ) Were soil samples analyzed? Yes NaI BTXE /ri PH-GIZITPH-DI Pb/ED8 <br /> Type of failure/discharge ) catastrophic tong- term leakage IaverfiLL I unknown other: <br /> IV- ,REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL AN { n 1445 <br /> Hallwb d 466(y <br /> SoiL Samples Received Yesl No Depth to Ground Waterl q IRef/Yearl q S Average Annual Precipitation ) A= 114 10 - 25 <br /> On- Site We ( L ( s ) I Yes x 1 No INurtber & Typel Irr X Oaml IPuaI <br /> S Scare S Score S Scare <br /> Distance to WeLL ( s ) from rank P.0 ft; ft ; ft C 10 ots C 9 pts C 5 pts <br /> 0 if 0 if O if <br /> R condition R condition R condition <br /> V , Site Feature - Leaching Potential Analysis - is met _ is met _ is met <br /> 1Minim Depth to groundwater from the Soil Sample ( feet ) I > 100 I 151 - 100 25 _50\ 1 <br /> ) Fractures in subsurface ( applies cc foothills or mountain areas ) h I None I I Unknown ) Present <br /> ( Average Annual Precipitation ( inches ) lxxxxxxl < 10 9 10- 25 lxxxxxxxl 26- 40\2 <br /> Man-Made canduits which increase vertical migration <br /> of Leachate ( i . e- , septic systems , water wells , ponds ) None I Unknown Present <br /> Unique site features : Recharge area , coarse soil , nearby wells . IxXxxxx None At least ) More than <br /> GI one one <br /> COLUMN iOTALS> » TOTAL POINTS I � U + l � . <br /> Sample Result : ( B i X OR E) RANGE OF TOTAL POINTS 49 pcs or more 41 - 48 ors I 40 pts or Less 1 <br /> i' `t1J JYA w30 f 7( ��epw} �H MAXIMUM ALLOWABL' 3 - T- X-E L_=4EL5 (PPM) tl 50II <br /> 50 50 -3I .3 7 . i - I NA\3 <br /> j5 'Le Result: -_ GASOLINE 7000 I 100 - 10 <br /> � v"s W MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> epkon ��� TPH DIESEL 10 , 000 1000 l 100 <br /> ' FOOTNOTES : ^ tf doccmenred soft and/or ground water contamination is present , do not cpmplete the Leaching potential <br /> analysts - ( i - e- , site is currently on UGT Contamination List for soil or ground water . ) <br /> \ 1If depth is > 5 ft. and < 25 ft. , Scare 0 points. If depth (=5 ft- , do not use table, <br /> \2 <br /> If precipitation is > 40 inches , score G points . <br /> \3 Levels for STXBE are not applicable at a TPH concentration of 10 ppm (gasoline ) or 100 ppm (diesel ) . <br /> STAFF RECCMMEHDATION/CONCLUSION <br /> 1�Are BTX 3 E or TPH Cancenrrations > Allowable Levels "Yes ) X [ NaI --�� <br /> 2. Recomiend Site Closure ) Yesl No .� If Yes , Refer to Site Mitigation for Evaluation ) <br /> I . REVIEW EVALUATION - i0 BE COMPLETED BY A SUPERVISOR/SEHI0.R / <br /> CONCUR WITH STAFF .RECOMMENDATION FOR CLOSURE I YES1 1N0 REFERRED i0 SITE MITIGATION FOR EVALUATIONIYESI LINO I <br /> DATE REFERRED1 I [ DATE C4MRE LETTER MAILED [ I <br /> HARE OF n <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT) \5/90 <br />