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SAN joAQUIN COU" ?USLIC HEALTH SERVIC=S/EAVIRONMENTAL HEALTF +ISION DATE <br /> 64., SHEET FCR SITE CLOSURE EVALUATION � S <br /> 5VEEP5 COOS <br /> ME. OF FACILITY <br /> TANK ID <br /> `ADORESS 5, <br /> TANK SIZE 71 DOD FUEL TYPE LA-A <br /> I. GENERAL �C}SQ�ORY �• *• <br /> Doc.Sail/GV Cont l <br /> Is permit CurrMt? Yrs x0 Permit i! - Facy Status Code es No <br /> Nurber of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl DuaE <br /> II. TANK HISTORY <br /> iWas Tank tested? Yes No Failed precision test T yes No If yes, give dIII,ce{s) ! / <br /> I USG <br /> Mas a repair made to the tank systems Yes No 14 yes, ghat was repaired? <br /> t� <br /> IWas repair done under inspection? Yes No I here sail samples analyzed? Yes Ha BT%E TPH-G TPH-D - Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill . unkno►ai other: <br /> :V. REMOVAL HISTORY (ATTACH INSPECTION SIEPCRT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> /, Average Aal precipitation A� 14 10.25 <br /> Sail Samples Received Yes No Depth to Ground Vater LSD Ref/year ��; rcu <br /> On-Site llell{s) Yes No Number L Type 1rr Dom Pub <br /> S Score 5 Score 5 Score <br /> ft C pts C pia CPts <br /> Distance to Wellif i <br /> O f 0 f <br /> Wells) from Tank ft; ft; O 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 /> I!{inimum Depth to grour water from the Soil Sample (feet) <br /> X100 q 51-1a0 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None <br /> Unknown Present <br /> Average Annual Precipitation Cinches) <br /> xxxxxx 410 9 10-25 xxxxx�cx 26-40\2 <br /> Han-Made conduits which increase vertical migration r None � Unkrbwn Present <br /> of leachate (i.e., septic systems, water wells, ponds) <br /> ,y At least gore than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None C one <br /> COLLM TOTALS»>TOTAL POINTS <br /> Sample Result: (S T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> rr- 3Q. I" %/ I+rJSSD B T % E 9 T X E <br /> . 1�{ <br /> KI ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 \3 <br /> .3 1. i. <br /> NA <br /> GASOLINE 1000 100 10 <br /> Sample Result: <br /> D �(Q�� kk� MAXIMUM ALLOSiABLE TP H LEVELS QPM) 10010,000 5000 10O <br /> TPH <br /> FOOTNOTES: If documented salt aa., <br /> ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.a., site is currently an UGT LMtit �pthtion 5 fist fornsoilot or <br /> rtground water.) <br /> \1 if depth is > 5 ft. and < ZS ft., scare 0 points. <br /> \Z If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for STX3E are not applicable at a TPR concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECCmMENDATICm/CONCLUSION <br /> 1. Are BTX L E ar TPH Coneentrations -v Alloweblt levels *les Na <br /> 2. Recommend Site Closure Yes No If yes, Rifer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO Be COKPLETED BY A SUPERVISCAISENICR <br /> FEVALUATCR <br /> WITH STAFF RECCtWEHDATION FOR CLOSURE YES HO REFERRED TO SITE MITIGATION �FMEVA�11W YES NOFERREDDATE CLO5IJRE LETTER KAiL£D ! <br /> EH 23 a0 (UGTVKSHT)\5/90 <br />