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SAN JOAQUIN COUN' tLiC HEALTH SERVICES/ENVIRONMENTAL HEALTH DLVISION <br /> U1 [\,L,,,XSHEET FOR SITE CLOSURE EVALUATION \� DATE <br /> sSWEc1S CCOE <br /> NAME OF FACILITY �7 r •� ��' / j�i� �/2✓ fC-" <br /> �/Gs <br /> ;ADORES:- �__ f- -,- � -�0s-, TAMC IO # <br /> TANK SIZE FUEL TYPE 3- <br /> tit. GENERAL SITE HISTORY /' .++ <br /> Is permit currents Yes No Permit # - Facility Status Code Ooc.Soit/GW Cont Yes No <br /> Nuiber of Tanks at facility Age of Tanks(if available) Typo of Tank Steel Fbrgl Sngl Dual <br /> III. TANX HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 Yes No if yes, give date(s) <br /> Was a repair made to the tank system? Yes Me If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPH-OI Pb/E08 <br /> Type of failure/discharge catastrophic long-term Leakage overfill unknown other: <br /> IV. REMOVAL 4ISTORY (ATTACH INSPECTICH REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yss No Depth to Ground Water�-� Ref/Tear jage Arv+ual Precipitation A= 14 10-25 <br /> Cn-Site Wells) Yes No it <br /> Number b Type Irr Dam Pub <br /> S ScorS Score S Score <br /> Distance :o WetL(s) from Tank �� ft; ___,ft; ft C if C i pts C ifpcI0 if0 ifR conR condition R conditionV. Sire Feature - Leaching Potential AnalysisE is E is mat E is met <br /> 25-50\1 <br /> INinimun Depth to groundwater from the Soil Sample (feet) ,•,I T <br /> !!ate >100 51-100 1 <br /> Fractures in subsurface (applies to foothills or Mountain areas) <br /> zone � Unknown (Present <br /> Average Annual Precipitation (inches) <br /> xxxxxx <10 9 10-25 xxxxxxx 26.40\2 <br /> ✓ <br /> Man-Made conduits which increase vertical migration ) None Unknown "� Present <br /> of leachate (i.e., septic systems, water wells, ponds <br /> At Least ✓ More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None one <br /> l7 one <br /> SE��/ -Toe VC-,- rrASf�• W EGt� <br /> COLUMN TOTALS»>TOTAL POINTS - <br /> 40 pts or ass <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 4a pts <br /> l <br /> I X E j B T X E <br /> .•�•��F/ +% MAXIKM ALLOWABLE B-T•X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. E. <br /> ►u\3 <br /> GASOLINE 1000 100 10 <br /> sample Result: 100 <br /> MAXIMUM ALLOWABLE TPH LEVELS (P�) DIESEL 10,000 1000 <br /> ?_ {pr1�TPH—!� <br /> FOOTNOTES: <br /> '"If doc msnted soil and/or gra water contamination is present, do not complete the loathing potential <br /> analysis. (i.e., site is currently on UGT Contzminat<S ft., dofor <br /> notiusartablc� water. <br /> \1 If depth is > <br /> \2 If precipitation is > 40 inches, score 0 points. el). <br /> \3 Levels for BTXLE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (dies <br /> VI. STAFF RECOMMENDATION/CONCLUSICH <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels 'Yes 10 No <br /> 2. Recommend Site Closure <br /> Its No / *If Yes, Refer to Site Mitigation for Evaluation I Z <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> TES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES <br /> CCNGJR WITH STAFF RECOMMENDATION FOR CLOSURE x0 <br /> DATE REFERRED � <br /> GATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 30 (UGTWKSHT)\5/90 <br />