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SAN JOAQUIN COUNTYLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH D'- TON <br /> UGSTVKSHEET FOR SITE CLOSURE EVALUATION <br /> NAME OF FACILITY 1 SWEEPS CODE <br /> ADORESS TANK 10 S <br /> TANK SIZE ( FUEL TYPE `r'��n �� . <br /> 11. GENERAL SITE HISTORY <br /> r+r <br /> Is permit current? Yes No Permit 0 - Facility Status Code Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> III, TANK HISTORY <br /> Was Tank tested? Yes No Failed 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 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 /> Soil Samples Received Yes No Depth to Ground Water Ref/Year � _/4.�; Average Arcual Precipitation A-114 10-25 <br /> On-Site WeII(s) Yes No Number 8 Type Irr Dom Pub <br /> S Score 5 Score S Scare <br /> Distance to Wells) 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)j;-ic _J> >100 51-100 S 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None c Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 1 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration) <br /> of Leachate (i.e., septic systems, water wells, ponds) None �� Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None l one one <br /> COLUMN TOTALS»>TOTAL POINTS b JL *- -.S <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> ,err E -= n> a <br /> g .TX.B T X E B E <br /> MXI) )M ALLOWABLE B- 3 1 <br /> 1. i NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> PH L—� MAXIMUM ALLOWABLE TPN LEVELS (PPM) DIESEL 10,000 II 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not come the leaching potential <br /> analysis. (i.e., site is currently on UGT Contaainetion 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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION %�{'4-evm nc c S��-•+ <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels *Yes No V Gr = �(�-rr`" — Df i�•'Ic �wk, <br /> 2. Recommend Site Closure Yes *If Yes, Refer to Site Mitigation for Evaluation �� �• p/'/'�' `'I`" <br /> a = <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES 1,4kIN01 EFERRED TO SITE MITIGATION FOR EVALUATION ES NO <br /> DATE REFERRED / / DATE CLOSUR MA <br /> NAME OF 4 , <br /> EVALUATOR <br /> EH 13 BO (UGTWKSNT 5/9% <br />