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SAN JOAOUIN COUk0UBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTHOISION DATE C� C <br /> LOST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> 1. <br /> SWEEPS CODE <br /> NAME OF FACILITY 1 L,Sy� NE . <br /> ADDRESS 2_C:> Q VJ T(J IZ N '_J TANK ID # 13 <br /> TANK SIZE 10 C'OD FUEL TYPE <br /> 11. GENERAL SITE HISTORY *** <br /> Is permit current? Yes No Y Permit # - Facility Status Cade Doa.Soil/GW Cont Yes No <br /> Number of Tanks at facilitType of Tank Steel FbrgL Sngl Dual <br /> y Age of Tanks(if available) <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 TPN-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 /> Q Average Annual Precipitation A= 14 10-25 <br /> Soil Samples Received Yes No Dapth to Ground ; <br /> Water - Ref/Year rr�] <br /> On-Site WeLL(S) Yes No V Number 8 Type Irr Dan Pub <br /> 5 Score S Score S Score <br /> Distance to WeLL(s) from Tank ft; it; 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) 30 — <br /> >100 51-100 L) 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> None Unknown Present <br /> xxxxxx 410 9 10-25 xxxxxxx 26-40\2 <br /> Average Annual Precipitation (inches) <br /> Man-Made conduits which increase vertical migration None G' Unknown Present <br /> of leachate (i.e., septic systems, water wells, ponds) <br /> At least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> U 2,'1 t o = 3-1 <br /> Sample Result: (B T % OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> 0::IWD L= IUD 8 T X E B T X E <br /> r4 k = go MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> 1000 100 10 <br /> Sample Result: <br /> GASOLINE <br /> 51.00 P Pm TPH. "'� MAXIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leachi <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 BTX&E are not appLicable at a TPH concentration of 10 ppm (gasoline) or 100 PPM (diesel). <br /> lyLco,,cC�%,<o . fat grYe <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> Q( C� sP� ?Jc�(JtOh <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No 1 <br /> No *If Yes, Refer to Site Mitigation for Evaluation <br /> 2. Recommend Site cl ..rFYeT, <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED 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 />