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SAN JOAQUIN BLIC HEALTH SERVICES/ENVIRONMENTAL HE4dhMISION <br /> I. low KSHEET FOR SITE CLOSURE EVALUATION 11W DATE' /'&7 <br /> NAME OF FACILITY SWE=oS CODEI a3/ <br /> ADDRESS R 7-ZJ0 az Lot , (TANK ID #1 -3 <br /> TANK SIZE / FUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit # - Facility Status Code Doc.SOil/GW Cant Yes No <br /> Number of Tanks at facility Age of Tanks(if available)1131 Type of TanklSteel Fbrgl ISngl I Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No Ifyes, 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?i Yes No Were sail samples analyzed? Yes No BTXE TPH-GI TPH-0 Pb/E08 <br /> Type of failure/discharge catastrophic (tong-term Leakage overfill Iunknownl Iother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water IRef/Year Average Anrwal Precipitation A= 14 10-25 <br /> On-Site Wells) Yes INo Number & Type Irr Doml Pub, <br /> S Score S Score S Scare <br /> Distance to WeIL(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if O if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) >100 I 51-100 I 125-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) I None Unknown (Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 110-25 Ixxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, nater wells, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. I At least More than <br /> Xxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + + I = <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 - 48 pts I 40 pts or less <br /> B T I XE B JT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50� 50 .3 .3 t. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAX%NRJ}I ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <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 sail 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 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 'Yes No <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evatuation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES! INOI (REFERRED TO SITE MITIGATION FOR EVALUATION YE5 NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED / / <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />