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SAN JOAQUIN COUNTY 1 IC HEALTH SERVICES/EIIVIRO <br /> NMENTAL HEALTH DIVISION <br /> f UGS7 t ..XSHEET FOR SITE CLOSURE EVALUATION T <br /> NAME OF FAGILITY � A 7-3— <br /> � <br /> zeyl <br /> r A - DATE j�,? <br /> SWEEPS CODE [/! � <br /> ADORESS 'z C-, iG j G <br /> TANK ID # <br /> TANK SIZE � ��4��) FUEL TYPE &2 <br /> It. GENERAL SITE HISTORY <br /> ]1spermit current? Yes No Permit # �%,ks�(If <br /> acility Status Code �C'; DpC,5as1/� Cont Yes No <br /> ber of Tanks at facitity , Age a able) J <br /> Type of Tank steel Fbrg[ Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No >( Failed precision test T Yes No Ifes give Y 9 date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair none under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPH-D :.08 <br /> is <br /> Type of failure/discharge catastrophic [ono-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Sail Samples Received Yes No Depth to Ground Water ;rj Ref/Year <6 ; <br /> Average Annual precipitation An 14 -110-251 <br /> On-Site Wells) Yes No Number & Type Irr Dom Pub <br /> Distance to We[t(s) from Tank ft1S Score S Score S Score <br /> ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> V. Site Feature - Leaching Potential Ana! R condition R condition R condition <br /> Analysis E is met E is met E <br /> is met <br /> Minimum Depth .to groundwater from, the Soil Sample (feet) <br /> 3.100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> <J None Unknown. Present <br /> Average Annual Precipitation (inches) <br /> xxxxxx <10 9 10-25 xxxxxxx 26-60\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water hells, ponds) IV//''!! <br /> Nom Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. <br /> At Least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS /1 + Ig"C } CD <br /> a `� <br /> Sample Result: (B T X OR E) RANGE OF TOTAL. POINTS 49 pts or more v 41 - 48 pts 40 pts or', ess <br /> -7 ,o�� x_ ,os's <br /> C21 O MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 E .3 .3 1. 1. <br /> Sample Result: <br /> NA\3 <br /> IMAXIMUM ALLOWABLE TPN LEVELS (PPM)LGASOLINE1000 100 . 10 <br /> TPNESEL 10,000 <br /> 1000 100 <br /> FOOTNOTES: <br /> If documented soft and/or ground water contamination is present, do not complete the (each i <br /> I at <br /> analysis. (i.e., site is currently on UGT Contamination fist for 5011 or ground water.}���t�w <br /> k1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <x5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TAN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TAH Concentrations > Allowable Levels •Yes No a/ a ;L <br /> 2. Recommend site Closure Yes Na X *If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / C� / /� DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> P <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> r <br />