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p� <br /> SAN JOAQUIN rifi "-Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL v- DIVISION <br /> I . uUST WORKSHEET FOR SITE CLOSURE EVALUATION DATE4 - <br /> NAME OF FACILITY `-1 wLC.. ��G SWEEPS CODE <br /> ADDRESS ,� O nv,) TANK ID '� 39 - �3z-�S - 02 <br /> TANK SIZE )Q FUEL TYPE Q� 1 7 <br /> I1 - GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit # - Facility Status Code DOc .Sait/GW Cant Yes No <br /> Number of Tanks at facility Age of Tanks( if available) L,jM Type of Tank Steel Fbrgl SngL Dual <br /> LII . TANK HISTORY <br /> Was Tank tested? Yes Na x Failed precision test 1- Yes No If yes , give date( s ) <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 sail samples analyzed? Yes I VING BTXE TPH-G TPH-13 Pb/ED <br /> Type of failure/discharge catastrophic Long- term Leakage overfill x unknown 01other : <br /> n As v <br /> IV . REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECTDATA FOR LEACHI TENTIAL ' ANALYSIS) <br /> Soil Samples Received Yes 'x No Depth to=Ground "'l Ref/Yea RS ; Average Annual Precipitation A= 14 10 - 25 <br /> On- Site WeLL ( S ) Yes No Number & Type X Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to WeLL (s ) from Tank 2 ft ; ft ; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 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 /> Minimum Depth to groundwater from the Soil Sample ( feet ) > 100 51 - 100 25-50\ 1 <br /> Fractures in subsurface ( applies to foothills or mountain areas ) V None Unknown Present <br /> Average Annual Precipitation ( inches ) xxxxxx ( 10 9 10- 25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate ( i . e . , septic systems , water watts , ponds ) None Unknown '> +Pre8ent <br /> Unique site features : Recharge area , coarse soil , nearby wells . At least rethan <br /> xxxxxx None one2 one <br /> COLUMN TOTALS> >>TOTAL POINTS C7 + U * U = ✓�j <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 X E B T X E <br /> hlD ICU ly �D I IMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1 . 1 . NA\3 <br /> Samm�ppp a Res ltq: GASOLINE 1000 100 10 <br /> Cions MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 82_ :=TPH Qom,,, DIESEL 10 , 000 1000 100 <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 UST Contamination List far 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 . <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 x No <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 />