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SAN JOAQLJi PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA 111 ON <br />I. LST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 711 51q, <br />I.ME OF FACILITY I� �- qv ECORD ID <br />r DDRESS IU,!i' ITANK ID 91 - <br />ANK SIZE I7S'D G '� IUEL TYPE <br />permit current? es o ermit # lFacitity Status Code oc.Soil/GW Cont es o <br />fiber of Tanks at facility ge of Tank(if available) ype of Tank ISteed Fbrgl I Isngl Dual <br />III. TANK HISTORY <br />as Tank tested? <br />as <br />o <br />o <br />ailed precision test ? es <br />?j j <br />o <br />6 verage Annual Precipitation <br />If yes, give date(s) <br />as a repair made to the tank system? es I No <br />f yes, what was repaired7 <br />as repair done under inspection? es o <br />ere soil samples analyzed? es o <br />TXE PH -G PH -D b/EDB <br />ype of failure/discharge <br />atastrophic tong -term leakage <br />verfill <br />own <br />they: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />oil Samples Received fes <br />fES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES <br />o <br />)ATE REFERRED <br />epth to Ground Water <br />?j j <br />of/Year <br />6 verage Annual Precipitation <br />n -Site WedL(s)IYes o <br />umber & Type <br />Irr <br />om <br />ub <br />� <br />S <br />Score <br />10 pts <br />if <br />S <br />C <br />0 <br />Score <br />9 pts <br />if <br />S <br />Cis <br />0 <br />core <br />fp <br />Distance to WeLL(S) from Tank ft; ft; ft C <br />0 <br />ondition <br />R <br />condition <br />R <br />ondition <br />R <br />V. Site Feature - Leaching Potential Analysis E <br />is met <br />E <br />is met <br />E <br />s met <br />Minimum Depth to groundwater from the Soil Sample (feet) 2 0 ® <br />>100 <br />I <br />1-100 <br />( ® <br />25-50\1 <br />fractures in subsurface (applies to foothills or mountain areas) <br />None <br />pt <br />Unknown <br />resent <br />I <br />verage Annual Precipitation (inches) KXXXXX <br /><10 <br />9 <br />10-25 <br />xxxxxxx <br />26-4012 <br />an -Made conduits which increase vertical migration <br />f leachate (i.e., septic systems, water wells, ponds) <br />None <br />� <br />Unknow <br />resent <br />nigue site features: Recharge area, coarse soil, or wells. <br />l <br />(Muncipal=>2000 ft; domestic=>500 ft; irr/agricultura =present] x <br />None <br />R <br />At Least <br />one <br />ore than <br />one <br />COLUMN TOTALS»>TOTAL POINTS <br />ample Result: (B 7 X OR E) <br />RANGE OF TOTAL POINTS 9 pts or more ( <br />41 - 48 pts <br />-"'""4U"pfs7o less <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 50 <br />.3 <br />.3 1. 1. <br />Sample Result: <br />SOLINE 1000 <br />100 <br />10 <br />N ® ° /•� TPH®' <br />AXIMUM ALLOWABLE TPH LEVELS (PPM) <br />IESEL <br />10,000 <br />1000 <br />100 <br />OOOTNOTES: ***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 />11 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 TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI . STAFF RECOMMENDATION/CONCLUSION <br />�1. Are BTX & E or TPH Concentrations > Allowable Levels Yeso 4 -6-- <br />2. Recommend Site Closure es lx�o <br />If Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO BE COM LETED BY A SUPERVISOR/LEAD SENIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE <br />fES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES <br />0 <br />)ATE REFERRED <br />/ / <br />ATE CLOSURE LETTER MAILED <br />AME OF <br />VALUATOR <br />EH 23 80 (UGTWKSHT)\5/94 <br />