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46 <br />SAN JOAQUIN C PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA IVISION <br />i. WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br />nME Of FACILITY S,� �'�- �� �„ <br />EEPS CODE <br />OORESS r ANK ID # 'j� • lG�{�- <br />TANK SIZE 6,4 UEL TYPE p,5 <br />I I e rre uremov <br />permit current7 es o ermi3 #„, .�;� acil�rTy St ��u &AI cm oc.Soil/GW Cont es o <br />fiber of Tanks at facility I Z� <br />ge of Tanks(if available) IType of Tank teel I Fbrgl ngl Dual <br />III. TANK HISTORY <br />Jas Tank tested? <br />es <br />EFERRED TO SITE MITIGATION FOR EVALUATION ES <br />o <br />1 Xtalted <br />precision test ? <br />es <br />I <br />o <br />if <br />yes, give date(s) <br />0-25 <br />as a repair made to the tan system? es No 11f yes, what was repaired? <br />JYes <br />as repair done under inspection? <br />No ere soil samples analyzed? <br />es <br />umber & Type <br />o <br />Irr <br />TXE <br />cm <br />PH -G <br />PH.0 <br />Score <br />10 pts <br />b/EDB <br />S <br />pts C <br />ype of failure/discharge <br />istance to Wells) from Tank <br />atastrophic long-term leakage <br />verfill <br />if <br />ondition <br />is met <br />nknown <br />0 <br />ondition R <br />met E <br />cher: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA PUR Ltwcninu nnnL— —1 <br />oil Samples Received es <br />ES 0 <br />EFERRED TO SITE MITIGATION FOR EVALUATION ES <br />o <br />0 <br />epth to Ground Water <br />of/Year <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE <br />verage Annual Precipitation <br />= <br />4 <br />0-25 <br />-Site Wells) <br />JYes <br />I <br />o <br />I <br />umber & Type <br />Irr <br />cm <br />Lb <br />S <br />Score <br />10 pts <br />S Score <br />C 9 <br />S <br />pts C <br />3core <br />5 pts <br />.f <br />istance to Wells) from Tank <br />ft; ft; ft C <br />0 <br />if <br />ondition <br />is met <br />0 if <br />R <br />E is <br />0 <br />ondition R <br />met E <br />ondition <br />is met <br />R <br />Site Feature - Leaching Potential Analysis E <br />inimun Depth to groundwater from the Soil Sample Veet) <br />>100 <br />1-100 <br />25-50\1 <br />ractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />aresent <br />verage Annual Precipitation (inches) xxxxx <br /><10 <br />9 <br />10-25 xxxxxxx <br />26-40\2 <br />an -Made conduits which increase vertical migration <br />Unknown <br />Dresent <br />f leachate (i.e., septic systems, water wells, ponds) <br />None <br />nide site features: Recharge area, coarse soil, nearby welts. <br />At least <br />4ore than <br />xxxx <br />None <br />one <br />one <br />+ <br />' <br />COLUMN TOTALS>>>TOTAL POINTS <br />o <br />a to Result: (B T X ORE) <br />RANGE OF TOTAL POINTS 9 pts or more <br />41 - 48 pts 40 pts or less <br />/I/Q .Cv5rja-7 F IVi$i <br />I-- !j'40ur .,W -f `I <br />B <br />T <br />X <br />E <br />B <br />X <br />E <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 <br />50 <br />1 <br />50 <br />50 <br />.3 <br />JT <br />.3 <br />1. <br />t. NA\3 <br />ampte Result: <br />SASOLINE 1000 <br />100 10 <br />AXIMUM ALLOWABLE TPH LEVELS (PPM) <br />100 <br />-(��%pvr! <br />TPH -? <br />IESEL 10,000 <br />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 BTX&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />Vt. STAFF RECOMMENDATION/CONCLUSION .0 "Sf”°i 44-4 - 7 - q(7 <br />1. Are BTX $ E or TPN Concentrations > Allowable Levels Yes o <br />2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br />--�'`I <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />ES 0 <br />EFERRED TO SITE MITIGATION FOR EVALUATION ES <br />0 <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE <br />ATE REFERRED <br />/ / <br />ATE CLOSURE LETTER MAILED <br />% / <br />TAME OF <br />:VALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />