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SAN JOAQUIN (7' INTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAT"1 DIVISION DATE( <br /> I, ST b'CRKSHEET FCR SITE CLOSURE EVALUATION i <br /> NAME OF FACILITY Iac Al e 1SWE=PS COOP-1 © 5 <br /> ADDRESS (TANK ID 4I •�a G -- <br /> TANK SIzEI ;`,Ora 9FUEL TYPE( G AS /�� ,2 s_v <br /> b �c <br /> It. GENERAL SITE HISZdRY, <br /> *** <br /> Is permit current?IYes No Permit N% - Facility Status Codel 00c.Soil/GW Cont Yes INoI <br /> (Number of Tanks at facility )Age of Tanks(if available) Type of Tank steel IFbrgl Sngll Oual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes INo xiFailed precision test ?IYesI No lif yes, give date(s)l <br /> Was a repair made to the tank sys-.em?j`Yes7 No If yes, what was repaired? <br /> Was repair done under inspection) Yesl Nol Were soil samples analyzed? Yes) INoI BTXEI ITPH-GI ITPH-01 Pb/EDB <br /> Type of failure/discharge% catastrophic hong-term Leakage Ioverfill Iunknown I other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes Hol (Depth to Ground Water �IRef/Yearl ; Average Annual PrecipitationlA= 14 10-25 <br /> On-Site Well(s)IYes I INoI (Number & Type Iirr (Dam) IPubI <br /> S Score S Score S Score <br /> (Distance to Wells) from Tankl 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) C I >100 I I51-100 125-10\1 <br /> (Fractures in subsurface (applies to foothills or mountain areas) + �i Hone I I Unknown I (Present <br /> lAverage ,annual Precipitation (inches) xxxxxxl <10 I 9 1 10-25 Ixxxxxxxl 26-40\2 <br /> (Man-Made conduits which increase vertical migration �o I I I I jPresent <br /> of leachate (i.e., septic system;, water wells, ponds) S1 �� None Unknown <br /> Unique site features: Recharge area, coarse soil, nearby wells. At leastMore than <br /> xxxxxx None I ( one) one <br /> COLUMN TOTALS>»TOTAL POINTS ' I + I (� I + 1 10 1.3 g <br /> Sample Result: (3 T X OR :) RANGE OF TOTAL POINTS 49 pts or more I 41 - 4a pts ( 40 pts or Less <br /> D 31T1X1 - 1 'B J.TIX1MAXIMUMALLOWABLE 3-T-X-E LEVELS (PPM) 1 50 S0 50 33 i 1. NA\3 <br /> Sample Result: H7GAWLIHE 1000 100 I 10 <br /> } D MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> N <br /> 'PH 10,000 % 1000 l� 100 <br /> FOOTNOTES: "*if documented soil and/or ground water contamination is present, do not complete the leachmn ential <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 3TX&E are not applicable at a TPH concentration of 10 ppm <br /> _� �(gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION! —r&! 2 <br /> 1. Are 3TX & E or TPH Concentrations r Allowable Levels I*Yes INo+ I P ie-c-e s,. <br /> 2. 2eco mmend Site Closure IYesl INoI II f Yes, Refer to Site Mitigation for 'Evaluation <br /> VII. REVIEW EVALUATION - TO 3E a PLETED 3Y A SUPERVISCR/SENIOR <br /> CONCUR 'JITH STAFF RECO"ENDATICN FOR CLOSUREIYESI INOI IREFERRED TO SITE MITIGATION FOR cVALUATICNIYESI INOI <br /> i <br /> DATE REFERRED( (DATE CLOSURE LETTER MAIL..DI <br /> NAME OF <br /> EVALUATORI <br /> EH 23 80 (UGTWKSHT)\5/90 <br />