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SAN JOAOUtH COU ''" PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH IVISION <br />RKSHEET FOR SITE CLOSURE EVALUATION GATE`J�-- <br />/ SU$SPS <br />NAME OF FACILITY 5 _ r ZG l�Of� C� <br />TANK ID* <br />ADORESS /L'/ O E� ��c z2 MO-7 <br />TANK SIZE /o2_0G0 FUEL TYPE <br />ll. GENERAL SITE HISTORY <br />Is permit current? Yes No -- Permit # Facility Status Code Doc.Soit/GLI Cont Yes No <br />Number of Tanks at facility Age of Tanks(if available) Type of Tank Stesl Fbrgt Sngl Dual <br />III. TANK HISTORY &'Y/ <br />ive dat/ <br />Was Tank tested? Yes No Failed precision test 1 Yes No If yes, g es) /p/ Y <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 saaptes analyzed? Yes No BTXE 7PH-G TPH-D Pb/EDB <br />Type of failure/discharge catastrophic long-term teek—el overfill unknown ther: <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 5-0 Ref/Year <br />Average Annual Precipitation A= 14 10-25 <br />on-Site Welts) Yes No Number & Type Irr Dom Pub <br />S Score S Score S ftScoffs <br />ft C 10 pts C 9 pts C ?fP <br />Distance to Welt(s) from Tank ft% _r-_____% 0 if 0 if <br />R condition R condition R condition <br />V. Site Feature - leaching Potential Analysis <br />l E is met E is met E is met <br />Minimism Depth to groundwater from the Soil Sample (feet) !Y <br />>100 51-100 XJ" 25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />None Unknown Present <br />xxxxxx <10 9 10-25 xxxxxxx 26.40\2 <br />Average Annual Precipitation (inches) <br />Man-Made conduits which increase vertical migration None C/ Unknown Present <br />of leachate (i.e., septic systems, water wells, ponds) <br />At least More than <br />Unique site features: Recharge area, coarse soil, nearby welts. xxxxxx None q one one <br />+ 5" yl <br />COLUMN TOTALS>»TOTAL POINTS <br />Sample Result: CB - E) !'v► <br />RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less, <br />B T X B T X E <br />N MUM ALLOWABLE B•T-X•E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\ <br />GASOLINE 1000 100 10 <br />Sample Result: <br />� TPM MAXIMUM ALLOWABLE TPN LEVELS (PPM) DIESEL 10,000 1000 /_ 100 <br />N <br />FOOTNOTES: <br />***If documented is present, not coaplet a leaching potential <br />mented soil and/or ground water contamination <br />analysis. (i.e., site is currently on UGT Contamination list do not usertable�. water. <br />\1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., <br />\2 If precipitation is > 40 inches, score 0 points. <br />\3 Levels for STXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />Vt. STAFF RECOMMENDATION/CONCLUSION GS+ <br />* 1'Cw�Ov wQ S � i ✓� � <br />1. Are BTX & E or TPH Concentrations > Att"ffe Levels Yes No2. Recommend Site Ctosure Yes No Yes, Refer to site Mitigation far Evaluation <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR J <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE TES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br />DATE REFERRED I / DATE CLOSURE LETTER MAILED / J <br />NAME OF <br />EVALUATOR <br />EH 23 80 (UGTWKSHT)\5190 <br />