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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> L• U" WORKSHEET FOR SITE CLOSURE EVALUATION _ DATE 3 <br /> NAME OF FACILITY - cP T- 5�.,: CODE <br /> ADDRESS �" L��L•l1 5 Cha TANK ID N ©0 ` '— <br /> TANK S[2: S "'v FUEL TYPE D ��Q`t ,s,/�� < <br /> [I. GENERAL SITE HISTORY // •�v v <br /> Is permit current? Yes No Permit 0 — Facility Status Codelqq <br /> Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY A20 ' <br /> Was Tank tested? Yes No Failed precision test ? Yes 40 If yes, give date(s) <br /> Was a repair made to the tank system? Yes No I If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPH-01 Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water 1ARef/Year Average Annual Precipitation A= 14 10-25 <br /> On-Site WeLL(s) Yes No Number & Type Irr Dam Pub <br /> S Score S Score S Scare <br /> Distance to Wells) 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 mat <br /> Minimum Depth to groundwater from the Soit Sample (feet) ( — 3� >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) Q None Unknown Present <br /> Average Annual Precipitation (inches) xx)o= <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration f <br /> of Leachate (i.e., septic systems, water wells, ponds) S* t'� None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby welts. At least More than <br /> xxx)= None one one <br /> COLUMN TOTALS>»TOTAL POINTS 10 + g + !J D = 3 g <br /> Sample Result: (S T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 48 pts 40 pts or less <br /> xC' M_l8 T X E B T X E <br /> MAXIMAALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 1. 1. y �N11\3 <br /> ! - <br /> Sample Result: GASOLINE 1000 100 10 1 <br /> MAXIKX ALLOWABLE TPN LEVELS (PPM) <br /> Uri ! TPH DIESEL 10,0001000 ]00 <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 an UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. rid < 25 ft., score 0 points. If depth <x5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXSE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION 'S cLa <br /> 1. Are BTX b E or TPH Concentrations > Allowable Levels *YesNo <�2�.�WC/. <br /> Z. Recommend Site Closure Yes NoIx If Yes, Refer to Site Mitigation for Evaluation �1/ l,J 077 ' �.— <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR 025 <br /> CONCUR WITH STAFF RECClMEMOATION FOR CLOSURE YES No REFERRED TO SITE MITIGATION FOR EVALUATION YES 0 <br /> DATE REFERRED /, DATE CLOSURE LETTER MAILED <br /> NAME OF I t <br /> EVALUATCR -- <br /> EH 23 30 (UGTWXSHT)\5/90 <br />