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SAN JOAQUIN COUNT C HEALTH SERVICES/ENVIRONMENTAL HEALTH - '' <br /> I. UC . .,:SHEET FOR SITE CLOSURE _VALUATICH DATE <br /> NAME Cf FACELITY G SWEEPS CODE <br /> aCDRF=SI TANK ID S <br /> TANK SIZE fv/odv FUEL TYPE Z r <br /> I1. GEN'--RAL SITE HISTORY <br /> Is permit current? Yes No Permit s - Facility Status Code Doe.Soit/GLI Cont Yes No <br /> Ih`:mer of Tanks ai facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngt Dual <br /> III. TANK HISTORY <br /> was Tank tested? Yes I mHo Failed precision test ?jYes7 H70 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 soil samples analyzed? Yes NoBTXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-tern leakage overfill unknownL. other: <br /> IV. REMOVAL HISTORY (ATTACK INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground water of/Year 9.6 ; g Average Acral Precipitation A* 14 10-25 <br /> Ori-Site Wells) Yes No NumIrr ber 3 Type Dom Pub <br /> S Score S Score S Score <br /> Distance to Welt(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) 3.100 51-100 25-50\1 <br /> Fractures In subsurface (applies to foothills or mountain areas) 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 wells, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than, <br /> xxxxxxi None one one <br /> COLUMN TOTALS»),TOTAL POINTS + + ' y� <br /> SampleR sutt: (itT X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts, 40 pts or less <br /> B T X E S T 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 /> 7J Ioo MAXIMUM ALLOWABLE TAH LEVELS (PPM) <br /> i TPR-O DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the Leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for 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 TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> ,�� <br /> Vl. STAFF RECOFPIENDATION/CONCLUSION <br /> 1. Are BTX & E or TPN Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE CC14PLETED BY A SUPERVISOR/SENIOR <br /> MNC.tR WITH STAFF REC04MENDATION FOR CLOSURE TES LINOt REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> OATE REFERRED / / �, DATE CLOSURE LEITER XAILED <br /> NAME OF <br /> EVALUATCR <br /> EH 23 30 (UGTWKSHT)\5/90 <br />