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E SAN JOAQUIN CCUR' 'USLIC HEALTH SERVICES/ENVIRONMENTAL HEALTF --�JISION <br /> U��IORKSHEET FOR SITE CLOSURE EVALUATION DATE I <br /> 1 <br /> IAME OF FACILITY / /� / ,,� �[f SWEEPS CODE <br /> -:Z3 <br /> 1 <br /> 1DDRESS <br /> �Y (D Cl JL/C�OYYLCC} 1 UG1L t tg�✓ TANK ID # <br /> TANK SIZE rQ DOt� FUEL TYPE I <br /> i <br /> GENERAL SITE HISTORY <br /> is permit current? Yes No Permit # Facility Status Codel C Doc.Soil/GW Cant Yes No <br /> lumber of Tanks at facility 3 Age of Tarks(if available) Type of Tank Steel ,Fbrgl S Dual <br /> f <br /> i. TANK HISTORY <br /> Jas Tank tested? Yes! Na Failed precision test ? Yes NoIf yes, give date(s) <br /> das a repair made to the tank system? Yes No if yes, what was repaired? <br /> las repair done under inspection? Yes No Were soil samples analyzed? Yes Nal BTXE TPH-G TPH-D Pb/EDBI <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br /> REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) � <br /> E Toil Samples Received Yes XI No Depth to Ground Water i�D Ref/Year ; Average Annual PrecipitationA=I14 10 25 <br />! 3n-Site Well s) Yes No Number 8, Type Irr Dam Pub <br /> S Score S Score S Score <br /> )istance 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 I� <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) 50—jC7, >100 51-10G 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) i nNone Unknown Present 1 <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 .5 Present <br /> Unique site features: Recharge area, coarse sail, nearby wells. R At least More than <br /> xxxxxx None 1 one one <br /> COLUMN TOT LS>>>TOTAL POINTS J + r 1 <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 48 pts 1--r0—pt. or less <br /> .r K LJ,2 s-r jV <br /> K 1v MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 1. NA\3 <br /> I I f <br /> Sampte Result: GASOLINE 1000 100 10 <br /> �K MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> km 13 PH9jp+A DIESEL 10,QGO 1000 100 <br /> t <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not coplete the eaching potentialmi <br /> analysis. (i.e., site is currently on UGT Contamination List for sail or grou <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 BTXBE are not appticabLe at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> STAFF RECOMMENDATION/CONCLUSION <br /> r K l c,S S a"V-� ip>a <br /> ,ter1. Are BTX 8 E or TPH Concentrations > ALLowable Levels *Yes Nof` — 1 <br /> 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for <br /> 1. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> I <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> 777 i <br /> DATE REFERRED DATE CLOSURE LETTER MAILED <br /> i <br /> NAME OF i <br /> EVALUATOR ! <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> • 1 <br />