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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DlVIS10N <br /> I. UG' ')ORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY Gf�Ei<po,�CGc � %MOO,�� Swc S CODE <br /> ADDRESS 7j d Zj G/�F,�dK Cc (/i"i r- I <br /> TANK ID # , '7��c� — '0 <br /> TANK SIZE FUEL TYPE <br /> 11. GENERAL SITE HISTORY ,a•�D <br /> Is permit current? Yes No Permit # Facility Status Code Doc.Soil/GW Cont Yes No <br /> Nuvber of Tanks at facility Age of Tanks(if available) Type of Tank Steel FbrgL Sngl Dual <br /> III. TANK HISTORY (--- . oYS1) l-1 a l <br /> Was Tank tested? Yes No Failed precision test ? Yes . No If yes, give dates) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done underinspection? Yea No were soil samples analyzed? Yes No BTXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Sail Samples Received Yes No Depth to Ground water Ref/Year A Average Annual Precipitation A• 14 10-25 <br /> On-Site weLL(s) Yen No Number 4 Type Irr Dam Pub <br /> S score S Score S Score <br /> Distance to We1L(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 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 Soil Sample (feet) >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 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> ([F/1NeA(, <br /> of leachate (i.e., septic system, water wells, ponds) Nora Utkr Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At Least More than <br /> xxxxxx None ane one <br /> / r ,�/ -e i 1-3. <br /> (V ocp-rN ) CO UIIN TALS> TOTAL POINTS <br /> Sample Result: IS T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> 8 T X E B T X E <br /> y= 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 /> MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> ' TPN DIESEL 10,000 1000 100 <br /> FOOTNOTES: *"If documented soil and/or ground water contamination is present, do not coaplete 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 STXdE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm Cdiese U. <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are 3TX I E or TPN Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No •If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECCNMENDATICM FOR CLOSURE 7ES NOI REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALL'ATCR <br /> I <br /> EH 23 30 (UGTWXSHT)\5/90 <br />