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SAN JOAQUIN Cl I PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAT •IVISION1. 7 <br /> RKSHEET FOR SITE CLOSURE EVALUATION DATE .7 <br /> NAME OF FACILITY b r PS CODE JZBZ <br /> ADDRESS 22bl �cvb �. TANK ID # - 0,5��-- ,y <br /> TANK SIZE 6 FUEL T E �pa+�81 !;I <br /> 11. GENERAL SITE HISTORY + + <br /> Is permit current? Yes No Permit # - Facility Status Code Q Doc.Soi l/GW Cont Y s No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngt Dual <br /> III. TANK HISTORY c;'+ �e5+ Ll Rv <br /> Was Tank tested? Yes No Failed precision test Yes No If as, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? 11 <br /> Was repair done under inspection? Yes o Were soil samples analyzed? Yes BTXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge ca strophic long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INS CTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACH <br /> ING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water Ip/ Ref/Year Annual Precipitation A= 14 10-25 <br /> On-Site Wells) Yes o Number & Type Irr Dan Pub Score S Score <br /> Distance to Wells) from Tank ft; fit; ft 9 pts C 5 pts <br /> if 0 if <br /> condition R conditionV. Site Feature - Leaching Potential Analysis is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet)—O Z >100 51-100 25-50\1 <br /> i <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 None Unknown Present <br /> of leachate (i.e., septic systems, Water welts, ponds) <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + + <br /> Sample ult• (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> N•V �� .5q+.toppM <br /> r '�m `l 1•I PP"" B T X E B T X E <br /> y^ t1.9 eem } $p�, �G}'�ip 11MUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> 11 <br /> Sam/p�le Result: • GASOLINE 1000 100 10 <br /> 2° �TITPH "IMUM 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 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 BTX&E, are not applicable at a TPH concen ation of t0 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION �1rJp <br /> 1. Are BTX & E or TPH Concentrations > All able Levels *Yes No ry <br /> 2. Recommend Site Closure Yes No *if Yes, Refer to Site Mitigation for Evaluation <br /> VII. 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 " a� <br /> EVALUATOR '--- <br /> EH 23.80 (UGTWKSHT)\5/90 <br />