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SAN JOAQUIN COUV'Y PUBLIC 4EALTH SERVICES/ENVIRONMENTAL HEALTH OIVISICN <br /> I' WAKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY '' SVE EPS CODE '1 / <br /> Aooa£ssI ITANK ID $I > �• ��47 —� <br /> TANK 3IZE FUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> ... <br /> Is permit currentt Yes No Permit P - Facility Status Code Doc.Soil/GW Cant No <br /> (Number of Tanks at facility Age of Tanks(if available) (Type of TanklSteel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> (Vas Lank tested7lYes Failed precision test 7 Yes No If yes, <br /> Was a repair made ;o the tank systeas? Yes No It yes, mat was repaired? i <br /> Was repair done raider inspection? Yes No Vere soil samples analyzed?)Yes Na STXE TPH•Gl ITPH-D Pb/EDS <br /> Type of failure/discharge catastrophic long-term leakage overfiLLI unknown I other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/CCLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Sanples Received Yes No Depth to Ground water) nus <br /> Ref/Year (Average A ) PrecipitationA• 14 10-25 <br /> Cn-Site Vell(s)I YesI INo (Number S Typel Irrl Doal (Pub <br /> S Score S Score S Score <br /> Distance to jell(s) frac Tank ft; _f t; 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 - Leeching Potential Ara lysis is met - is aet E is ret <br /> MiniIam Depth to groundwater from the Soil Sample (feet) >100 I51-100 l 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None I Unknewn Present <br /> Average Annual Precipitation (inches) Kxxz <10 9 110-25 KKSXKxK 26-40\2 <br /> Man-Made conduits 'which increase vertfcal aigratian <br /> of leachate (I-e., septic systems, water wells, ponds) more Unklu Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> ux:Ocx None <br /> and one <br /> COLUMM TOTALS>»TOTAL POINTS ♦ • a <br /> Sample Result: CS 7 X OR E) RANGE OF iOTAL POINTS 49 pts or more ( 41 48 pts 40 pts or less <br /> d T X 1 E 1 3 T X E <br /> MAXI" ALLWIIBLE 3-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Staple Result: GASOLINE 1000 l 100 10 <br /> MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: •••If doctmented soil andlor ground water cmtaninatim is present, do rot complete the leaching potential <br /> analysis. (i.a., site is currently on UGT Cmtaminatim List for soil or around 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 3TXSE are rot applicable at a TPN concentration of 10 Ppm (gasoline) or 100 ppm (diesel). <br /> VI. iTAFF RECCMMENDATION/CCNCLUSicm <br /> 1. Are 3TX i E or TPN Concentrations > Allowable levels (•Yes INo <br /> 2- Raeommerd site Ctosurel Yes) (NoI If Yes, Refer to Site Mitigation for Evaluati <br /> '/II. REVIEW EVALUATION - TO BE COMPLETED 3Y A SUPERVISOR/SENICR <br /> CONCUR WITH STAFF 3ECaW.40ATION FOR CLCSURE YES( N0j (REFERRED 10 SITE MITIGATION FOR EVALUATICNIYESI INOI l <br /> GATE REFERRED( / / (DATE CLOSURE LETTER MAILED( <br /> NAME CF <br /> c/ALUATCR <br /> EH 23 BO (UGTWXSHT)\5/90 <br />