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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I. "' WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITYG�i 0 ?PS CODE <br /> < �1 SCj C G_ I <br /> ADDRESS S 51 �' , I C�r. I TANK ID #1-35 <br /> TANK SIZE �C�O FUEL TYPE C6 1 Q <br /> 11. GENERAL SITE HISTORY <br /> IIs permit current? yes No X lPemit d - Facility Status Code :�C7 Doc.Soil/GW Cont Yes No <br /> Nurber of Tanks at facility I Aga of Tanks(it available) Type of Tank Steell IFbrgll ISngil Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? Yea No 4FaiLed precision test 7 Yes No If yes, 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? Yes No Were soil sanples analyzed? Yes ENHSTXE TPH-G TPH-O Pb/EDS <br /> Type of failure/discharge catastrophic long-term Leakage overfill urknowi other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No und Depth to GroWater �L, Ref/7ear fr-6 Average Annual Precipitation A- 14 10-25 <br /> On-Site Wells) Yea No Nunber b Type Irr �/ Oam Pub <br /> S Score S Score S Score <br /> Distance to WeLI(s) from Tank '� S ft; -2u ft; ft C 10 pis C 9 pis 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 net E is met <br /> Minimum Depth to groundwater frac the Soil Saiple (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 xxxzx><x 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systema, water wells, ponds) None Unknow[ Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At Least More than <br /> XXX)= None /� one U one <br /> COLUMN TOTALS»>TOTAL POINTS + 3 6 + S • I I <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 48 pts 40 pts or less <br /> B E B T X E <br /> (. �$ -x --Z -1 MAXI MLm( ALLOWABLE S-T-X•E LEVELS (PPM) 1 50750 50 .3 .3 1. 1. NA\3 <br /> Sanple Result: GASOLINE 1000 1 10 <br /> MAXIlIAI ALLWABIE TPN LEVELS (PPM) <br /> II�t�U TPM DIESEL 10,000 1000 100 <br /> FOOTNOTES: "'If documented soil and/or ground water contamination is present, do rot coapleta tha leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or grout water.) <br /> \1 if depth is > 5 ft. and < 25 ft., score 0 points. If depth o5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for STXBE are not applicable at a TPH concentration of 10 Pisa (gasoline) or 100 ppm (diesel). <br /> 'fi. STAFF RECCf41ENDATION/CONCLUSION <br /> 1. Are BTX i E or TPH Corcentrationa > Allowable Levels 'les No <br /> 77 <br /> l2. Recommend Site Closure Yes _[No! If Yes, Refer to Site Mitigation for Evaluation) <br /> VII. REVIEW EVALUATION - TO SE COMPLETED BY A SUPERVISOR/SENICR <br /> CCNCJR WITH STAFF RECCMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATIONIYES ' NOI <br /> DATE REFERRED G / / DATE CLOSURE LETTER MAILEDI / / <br /> NAME OF <br /> EVALUATOR - <br /> E4 23 30 (UGTWKSHT)\5/90 <br />