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I. <br />NAME OF FACILITY <br />ADDRESS .3 A/6 - <br />TANK SIZE JT` <br />SAN JOAQUtN COLJhPUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALT VISION <br />WORKSHEET FOR SITE ,CLOSURE EVALUATIONDATE <br />err <br />permit current? Yes No I Permit H Facility Status Cock 0Doc.Scit/GW Cant Yes ixNO <br />tuber of Tanks at facntity Age of Tanks(if available) Type of Pank Staet Flugt Sngl Dust <br />Ill. TANK HISTORY <br />Was Tank tested? <br />Yes <br />No <br />NO <br />Failed precision test ? <br />Yes <br />NO <br />W6 ; <br />If yes, give date(s) <br />As <br />Was a repair made to the tank system? <br />Was repair done under inepection? Yes <br />Yes No 1If yes, what was repaired? <br />No Were soil suptes analyzed? Yes No 8TXE TPN -G TPN -D Pb/88 <br />Type of failure/discharge <br />yes <br />catastrophiclong-term leakage <br />NoNuMber <br />overfill <br />& Type <br />Ir r <br />other: <br />tV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received Yes <br />NO <br />Depth to Ground Water461 <br />Ref/Year <br />W6 ; <br />Average Annual Precipitation <br />As <br />14 <br />10-25 <br />On -Site Wett{s) <br />yes <br />NoNuMber <br />& Type <br />Ir r <br />Dom <br />Pub <br />S <br />Score <br />10 pts <br />S <br />C <br />Score <br />9 pts <br />S .Score <br />C <br />5 pts <br />Distance to Wetl(s) from Tank <br />ft; ft; ft C <br />0 <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />condition <br />is not <br />0 iif <br />R <br />E <br />condition <br />is not <br />R <br />V. Site Feature - Leaching Potential Analysis E <br />Minimum Depth to groundwater from the salt Sample (feet) <br />>100 <br />51-100 <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />Present <br />Average Annual Precipitation (inches) xxx= <br /><10 <br />9 <br />10.25 <br />x=xxxx <br />26-40\2 <br />Han -Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknoun <br />Present <br />Unique site features: ,;Recharge area, coarse salt, nearby wells. <br />At Least <br />More than <br />xxxxxx <br />None <br />as <br />ala <br />COLUMN TOTALS»>TOTAL POINTS <br />4. <br />• <br />s <br />Sample Result: (S T X OR E) RANGE OF TOTAL POINTS 49 pts or sore 41 - 48 pts 40 pts or less <br />8 T X E 8 T X E <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br />Sample Result: GASOLINE 1000 100 10 <br />MAXI ALLOWABLETPN LEVELS CPPM) <br />TPN DIESEL 10,000 1000 100 <br />FOOTNOTES: "If documented soil and/or gratd water contamination is present, do not comptato the leaching potential <br />analysis. (i.e., site is currently an UGT Contamination List for soil or ground water.) <br />\1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth �m5 ft., do not use table. <br />\2 if precipitation is > 40 inches, score, 0 points. <br />\3 Levels for 3TX&E are not applicable at a TPN concentration of 10 ppo Cgssotine) or 100 ppm Cdteset). <br />VI. STAFF RECOMMENDATION/CONCLUSION <br />1. Are 8TX & E or TPN Concentrations > Attowabis Levels *Yes No <br />2. Recommend Site Ctosure Yes No If Yes, Refer to Site Mitigation for Evaluation <br />Vit. REVIEW EVALUATION - PO BE COMPLETED BY A SUPERVISOR/SEHIOR <br />WITH STAFF RECCMMEHOATION FOR CLOSURE YES NO R£ TO SITE MITIGATION FOR EVALUATION YES NO <br />DATE REFERRED / / DATE CLOSURE LETTER MAILED <br />NAME OF <br />EVALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />