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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> i "MkY WORKSHEET FOR SITE CLOSURE EVALUATION �' DATE 3 / Z — rj Z <br /> AKE OF FACILITY `Man s� / ~'6R€PS CODE L/ 7 9 <br /> ADDRESS /o G r� .51- i TANK ID Y 3 -�L1-7 _ [� <br /> TANK SIZE1000 � <br /> !I. GENERAL SITE HISTORY <br /> is permit current? Yes o Permit 6 - Facility Status Code 9 Doc.Sotl/GW Cont Yes i No <br /> Nuaber of Tanks at facility L/ Age of Tanks(if available) Type of Tank Steel rgl Sng( Duel <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No if yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes o BTXE 17FPH PH-D I Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill 111tunknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes o Depth to Ground Yater jo Ref/Year S-6 Average Annual Precipitation A= 14 10-25 <br /> On-Site Welts) Yes o lNumber S Type Dao Pub <br /> S Score S Score S Score <br /> Distance to WeLI(s) from Tank 3V 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 Soil Sample (feet) — >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) U None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, pads) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS 10 • 271 + J� <br /> Sample Result: (8 T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> X 7/O BT X E 8 T X E <br /> T 9'-1 E �,/00 WINUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. \3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> _TPH DIESEL 10,000 1000 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not Complete the leaching potential <br /> analysis. (i.e., site is Currently on UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXEE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are 8TX S E or TPH Concentrations > Atlowabte Levels *Yes No <br /> 2. Recommend Site Closure Yes No 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 REFERRED TO SITE MITIGATION FOR EVALUATION YES <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF � <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />