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r _- <br /> SAN JOAQUIN PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA 1vtSION <br /> I. �m&T WORKSHEET FOR SITE CLOSURE EVALUATION DATE j <br /> NAME OF FACILITY C CODE 73/ <br /> ADDRESS <br /> t ty�, TANK 10 #1 <br /> 1 <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit N - Facility Status Code Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) / Type of Tank Steel Fbrgl Sngl Dust <br /> III. TANK HISTORY "ee,40.1 <br /> , <br /> Was Tank tested? Yes No Failed precision test ? Yes No if yes, give date <br /> (s)Was a repair made to the tank systart yes No If yes, what was repaired?Was repair done under inspection? Yes No Were soil samplas analyzed? Yes NoType of failure/discharge catastrophic tong-term teakage overfill unknown o <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 'D Ref/Year gb Avere" Annual Precipitation A= 14 90-25 <br /> On-Site Wetl(s) Yes No Number A Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to Wetl(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 <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the soft Sample (feet) 'p--� 30100 51-100 25-5 <br /> Fractures in subsurface (applies to foothills or mountain areas) 10 gone Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10- xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical aigrstion J <br /> of leachate (i.e., septic systems, water walls, ponds) 1 �� None W0164Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More then <br /> xxxxxx N ane one <br /> COLUMN TOTALS»>TOTAL POINTS = 3 <br /> sammf R (8 T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or lessPt 1 <br /> 8 T X I E B T % E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Remit: GASOLINE low 100 10 <br /> A JY MAXIMM ALL06KBU TPH LEVELS (PPM) <br /> TPN DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leeching potential <br /> analysis. (i.e., site is currentty on UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <zS ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0-points.- <br /> \3 <br /> -points:\3 Levels for BTX&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RE( (DATION/CONCLUSION P. &ro c k p le k a- k <br /> 1. Are BTX i E or TPH.Concentrations > Allowable Levels *Yes Mo e+f ra leu/�`� "—z^' <br /> S P 1 R '=-1 J,Doe,pw,. <br /> 2. Recommend Site Closure Yas No If yes, Refer to Site Mitigation for Evaluation �PIS <br /> � 3 r,�DOD?Qn'^ <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR S P I C'>i . <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED ! / <br /> NAME OF <br /> EVALUATOR <br /> EN 23 30 (UGTWKSHT)\5 <br />