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t' SAN JOAQUIN MluTY PUBLIC HEALTH SERVICES/£HViRONMENTAL HEALT,hn VISION <br /> . NORKSHEET FOR SITE CL05URE EVALUATiOH [DATE <br /> " <br /> ! t <br /> FACILITY �A4 [EPS CODE 3 <br /> RESS iL G �`o TANK ID # <br /> TANK SILEIZ 1f/Sr� FUEL TYPEf <br /> II. GENERAL SITE(HIIS`TORY 26W <br /> Is permit current7 Yes a Permit # - Facility status Code Doc.SoiL/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) V� Type of Tank Steel rgt SngL Dual <br /> III. TANK HISTORY <br /> Was`Tank tested? Yes Ll�<) Failed precision test ? Yes , No If yes, give date s) <br /> Was.a repair-.made to the tank system? Yes No f yes., What was red? <br /> Lias"repair done under inspection? YesNo Were soil samples analyzed? Yes No BTXE TPH-G TPH-D Pb B <br /> Type of failure/discharge .. catastrophic Long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY tATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples""Received Yes No Depth to Ground Yater V Ref/Year ; Average Annual Precipitation A= 14 10.25 <br /> On-Site WeLL(S) Yes No umber & Type Iry Dom Pub S Score S Score S Score <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 <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) None Unknown Present <br /> Average Annual Precipitation (inches) x== <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) to None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least Mare than <br /> xxxxxx None one one <br /> COLUMN TOTALS>>TOTAL POINTS �� + 77 _ -5 7 <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts or le <br /> 81 T I X E B JT I X E <br /> _ MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1./ NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> !amu MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 110 °} �' TPH DIESEL 10,000 1000 1�' " <br /> FOOTNOTES: ***If documented sail and/or ground water contamination is present, do not complete th Leathing potentia <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or gro water J <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 <br /> Z. 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 ITO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILIIED <br /> NAME OF- <br /> EVALUATOR <br /> EH 23" ti0 (UGTWKSHT)\5/90 // <br />