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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/EHVIRONMENTAL HEALTH DIVISION pp�� . U ' ICRKSHEET FOR SITE CLOSURE EVALUATION --' DATE S— NAME OF FACILITY I K L Q `�"��s - StilLti'S CODE /672 ADDRESS 9C/g k/, C �� fj j`�.1 TANK ID # - 0� TANK SIZE FUEL TYPE G� l/ It. GENERAL SITE HISTORY Is permit current? Yes No Permit # - Facility Status Code Q Z Doe.S I/GW ContYes No Number of Tanks at facility Age of Tanks0 f available) 7 ,,5 Type of Tank Steel Fbrgl Sngl Dual III. TANK HISTORY Was Tank tested? Yes No Failed precision test Yes No If yes, give date(s) Was a repair made to the tank system? Yes No I V1If yes, what was repaired? Was repair done under inspection? Yes Were soil samples analyzed? Yes No BTXE TPH-G TPH-D Pb/EDB Type of failure/discharge cat strophic long-term leakage overfill unknown other: IV. REMOVAL HISTORY (ATTACH INSP CTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) Soil Samples Received YesI V1 No Depth to Ground Water IDr I Ref/Year ` fr TB b Average Annual Precipitation A= 14 10-25 On-Site WeIL(s) Yes No Number b Type Irr Dom Pub S Score S Score S Scorn Distance to Well(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts 0 if 0 if 0 if R condition R condition R condition V. Site Feature - Leaching Potential Analysis E is met E is met E is met Minimum Depth to groundwater from the Soil Sample (feet) I i I_ >100 51-100 25-50\1 Fractures in subsurface (applies to foothills or mountain areas) 01 None Unknown Present Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 Man-Made conduits which increase vertical migration of leachate (i.e., septic systems, water wells, ponds) None Unknown Present Unique site features: Recharge area, coarse soil, nearby wells. At least More than xxxxxx None one one COLUMN TOTALS>>>TOTAL POINTS + + I- Sample R suit: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less � PPM x,.11 Ppm '050 eem E"CP0 to MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 8 50 50 50 .3 .3 1. 1. NA\3 Sample Result: GASOLINE 1000 100 10 MAXIMUM ALLOWABLE TPH LEVELS (PPM) � M _TPH' DIESEL 10,000 1000 100 FOOTNOTES: ***if documented soil and/or ground water contamination is present, do not complete the leaching potential analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth u5 ft., do not use table. \2 If precipitation is > 40 inches, score 0 points. \3 Levels for 8TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). Vi. STAFF RECOMMENDATION/CONCLUSION 6,2 C}- I O d41 M Fr 1. Are BTX & E or TPH Concentrations > A owable Levels *Yes No 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/S NIOR CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO DATE REFERRED f� / /(� DATE CLOSURE LETTER MAILED NAME OF EVALUATOR ,� EH 23 80 (UGTWKSHT)\5/90