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1 SAN JOAQUIN CO PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL. <br /> UORKSHEET FOR SITE CLOSURE EVALUATION IVISfON <br /> NAME OF FACILITY S / DATE <br /> w3-j(, g <br /> Ct <br /> ADDRESS w�'�' / SWEEPS CODE <br /> •�/.5--� _ / � � <br /> 7✓'� TANK 10 # <br /> TANK SIZE -/V OFOI) FUEL YPE <br /> It. GENERAL SITE HISTORY <br /> !s permit current? Yes No Permit # <br /> Facility Status Code *** <br /> Number of Tanks at facility Doc-SOi L/GW Cont Yes No <br /> Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 1 Yes <br /> No If yes, give date(s) <br /> Was a repair made to the tank system? Yes Noy <br /> If es, what was repaired? <br /> Was repair done under inspection? Yes No I Were soil samples anal <br /> yzedl Yes No BTXE TPH-G TPH-D Ph/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 `ZJ Ref/Year <br /> S`6 ? Average Annual Precipitation A- 14 10-25 <br /> On-Site Wells) Yes No Number 8 Type Irr Dom Pub <br /> Distance to WeLL(s) from Tank "'--ft- S Score S Score <br /> —fit' ft C 10 is S Score <br /> \0 if P C 9 pts C 5 pts <br /> V. Site Feature - Leaching Potential Analysis 0 if 0 if <br /> R condition R condition R condition <br /> Minimum De th to groundwater from the Soil S E , ms met E ms met E ms met <br /> P g ample (feet) <br /> >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> NonL� Unknown Present <br /> Average Annual Precipitation (inches) <br /> xxxxxX <10 � <br /> Man-Made conduits which increase vertical migration 9 10-25 xxxxXXz 26-40\2 <br /> of leachate (i.e., septic systems, water wells, ponds) <br /> None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. <br /> xxxxxX None At at More than <br /> one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> Semple Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more - <br /> 3z' )1,6Z6 z-,z,¢y,v 41 48 [fts 40 pts or ss <br /> X w ,4 MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 ,3 1. 1 NA\3 <br /> Sample Result: ��, a� <br /> 3�/ y1W17,3,-) °�/3yL•MAAiMUM ALLOWABLE TPH LEVELS (PPM) GASOLINE 1000 0 10 <br /> TPH <br /> DIESEL 10,000 1009 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is resent, do <br /> analysis. (i.e., site is currently on UGT Contami-net4On-L4 SOIL <br /> the leaching potential <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points.(if depth c e, do <br /> soil ound water.) <br /> \2 If precipitation is > 40 inches, score 0 points. 5 ft., do not use table <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 <br /> Ppm (gasoline) or 100 ppa (diesel). . <br /> VI. STAFF 2ECOMMENDATION/CONCWSION <br /> f v/f.'. .OG Nk i) <br /> 1. Are BTX 8 E or TPN Concentrations > ALLOW le Levels *Yesf <br /> No <br /> 2. Recommend Site Closure Yes No If Yes, Refer t0 Site Mitigation for Evaluation <br />(11- REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR - <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES ..MOaR;EFEIR;R8D;TO SITE MITIGATION FOR EVALUATION YES ri,.- NODATE REFERRED / / DATE CLOSUR <br /> NAME OF <br /> EVALUATOR } <br /> EH 23 80 (UGTWKSHT)\5/90 <br />