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I SAN JOAQUINPUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH 0IVISION <br /> rLT,YMSHEET FOR SITE CLOSURE EVALUATION t DATEL:7 p <br /> NAME OF FACILITY <br /> f: Q EPS COOP <br />,+ ADDRESS �67 j IC/C! � TANff ID fi 3'T <br /> - OHO Z <br /> TANK SIZE �p / FUEL TYPE �,�r` <br /> It. GENERAL SITE HISTORY <br /> •e: <br /> Is permit current? Yes No Permit 9 - Facility Status Code Doc.Soit/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(If available) 4,.le Type of Tanks Steel Fbrgl Fl.Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes NoFatted precision test T Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repeired7 <br /> Was repair done under inspection? Yes No Wort soil swples analyzed? Yes No BTXE TPH-G TPH-D Pb/EDB <br /> Type of failureldischarge catastrophic I tong-terse leakage averfitl Htramwi other. <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILSICOLLECT OATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes I ANo Depth to Ground Water 40 Itef/Year-g6 ; Average Arrwel Precipitation A= 14 10-25 <br /> On-Site Wetl(s) Yes No Irr <br /> Number A Type Dom1 Pub <br /> 5 Score S Score S Score <br /> Distance to Well(s) from Tank ft; ft; ft C 10 pts C 9 pts C is pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature:- Leaching Potential Analysis E is met E Is met E is met <br /> Minimum Depth to groundwater from the Soit Sample (feet) 2-100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> Average Annual Precipitation {inches) xxxxxx <10 9 10-25 x000nxx 26-40\2 <br /> Nan-Made caxiuits which increase vertical migration <br /> of leachate (i.e., septic systems, water welts, ponds) None LArtkrwyn Present <br /> Unique site fekures: Recharge area, eosrse soil, nearby wells. At least More than <br /> xxx)oa Nave one one <br /> COLLM TOTALS>»TOTAL POINTS <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 43 pts 40 pts or Less <br /> B T I X I EB T X E <br /> MAXIML9i ALLOHABIE B•T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. i. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWBLE TRH LEVELS (PPM) <br /> 300 . �/ky` TPH DIESEL 10,000 100 <br /> FOOTNOTES: ***If docuwted soil and/or ground water contaminati s present, do not coaptote the lea ng potential <br /> analysis. (i.e., site is currently on UG t for soft round wat r.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 poi s. th a5 ft. do not use tab <br /> \2 if precipitation is > 40 inches, score 0 poin s. <br /> \3 Lavals for BTX3E are not applicable at a TPN antra or 100 ppm (diesel). <br /> Vt. STAFF RECOMMENDATION/CONCLUSION eAyc -r7., <br /> 1. Are STX 3 E or TPN Concentrations > Altowable Levels *Yes No <br /> 2. RecaaiaenI Site Closure Yes No Yes, Refer to Site Mitigation for Evatua <br /> VII. REVIEW EVALUATION - TO BE COMPLETED 31 A SLIP <br /> CCN=R WITH STAFF RECC1r MOATION FOR CLOSURE YES NO REFERRED TO SIIE MITIGATION FOR EVALUATION YES NO <br /> DATEREFERRED DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR44---II <br /> EH 23 30 (uGrASHT3\5/ <br /> i� <br />