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SAN JOAGUIN TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H DIVISION ry <br /> 1. ST WORKSHEET FOR SITE CLOSURE EVALUATION DATE( (Q.,� �O <br /> NAME OF FACILITY ' ` (SWEEPS CODE( <br /> ADDRESS1 32 3 d /V n ITANK ID X ,.a <br /> TANK SIZE 10)&-M FUEL TYPE( />/I/ <br /> II. GENERAL SITE HISTORY �{ G�Vv <br /> Is permit current? Yes XN01 (Permit A - Facility Status Code © 1 Daa..Sail/GW Cont)Yes No <br /> Number of Tanks at facility Age of Tanks(if available) 77 Type of Tank Steal Fbrgl Sngl Dual <br /> [iI. TANK HISTORY gp,t7 M,Gvt� ,5 r(y j 2 1160'+•t <br /> Was Tank tested? Yes No Failed precision test ?IYes IX <br /> No IIf yes, give date(s) <br /> Was a repair made to the tank system? Yes No IIf yes, what was repaired? <br /> Was repair done under inspection?I Yes Na Were soil samples am lysed? YesI INaI BTXEI ITP4-1I TPH-O I Pb/EDB <br /> Type of failure/discharge catastrophic (long-term Leakage Ioverfill unknown (other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAIL�S/nCOLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes NoI (Depth to Ground Water VFy) Ref/Year Average Annual Precipitation)A- 14 10-25 <br /> On-Site WeLL(S) Yefro <br /> s NoI Number & Type Irr am I IPubI <br /> S Score S Score S Score <br /> Distance to Wells) m 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)146- I >100 I 51-100 5 1. 25-50\l <br /> Fractures in subsurface (applies to foothills or mountain areas) ' I None I Unknown Present <br /> m <br /> Average Annual Precipitation (inches) Xxxxxx 00 I 9 110-25 Ixxxxxxxl 26-40\2 <br /> i <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) IO None Unknown (Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> XX)O=l Nane one) one <br /> COLUMN TOTALS>»TOTAL POINTS I _ Y3 <br /> Sample Res��/1,t 1: (8 T X OR E) RANGE OF TOTAL POINTS 49 pis or more I 40 ors or less <br /> K 3 '1 k X=, 00691 <br /> �y'J 9 T X E B T X -e <br /> MA%SI(UM ALLOWABLE B-T-X-c LEVELS (PPM) 1 50 501 50 .3 .3 1. 1. I NA\3 <br /> Sample Result: GASOLINE 1000 I 100 10 <br /> MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> �_TPH� DIESEL 10,000 1000 100 <br /> FOOTNOTES: '*'If documented soil and/or ground water contamination is present, donlet. 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 c5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, scare 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppe (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION T 9 3 O 4 STK 3 SIE <br /> 1. Are BTX & E or TPN Concentrations > Al towable Levels *yes No �j>,,,, ".-;L. -(�Z_. p� �C..r r✓ <br /> 2. Recommend Site Closure!Yes INo If Yes, Refer to Site Mitigation for EvaluationR�? fTW'V� -3 u,J <br /> VII. REVIEW EVALUATION - i0 BE COMPLc'fED BY A SUPERVISOR/SENIOR `'' yY_ 0'L�i W5 <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YESI INOI IREFERRED TO SITE 41TIGATICN FCR =VALUATION YEES( NCI <br /> DATE REFERRED / / DATE CLOSURE LETTER 9AILEDI <br /> NAME OF <br /> EVALUATORI <br /> EH 23 80 (UGTWKSHT)\5/90 <br />