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SAN JOAQUIN 0. i PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEI DIVISION <br /> I A*w�,T WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY A c -fo m4r/k o T#_r SWEEPS CODE <br /> ADDRESS 2 ` TANK ID is T.4,-0 Lf Ti S 0 1 y (J �2gyj <br /> TANK SIZE $� FUEL TYPE <br /> II. GENERAL SITE HISTORY *** <br /> Is permit current? Yes No Permit # - Facility Status Code Doc.SoiL/GW Cant Yes No V <br /> Number of Tanks at facility 2 Age of Tanks(if available) ij gj Type of Tank SteeL x Fbrgl 5ngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes x No If yes, what was repaired? w 5u <br /> Was repair done under inspection? Yes k No Were soil samples analyzed? Yes X No BTXE TPH-G TPH-D Pb/ED3 <br /> Type of failure/discharge catastrophic long-term Leakage overfill unknown other: III <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes x No Depth to Ground Water O Ref/YearIsp Gjn Average Annual Precipitation A=114 10-25 <br /> On-Site Well(s) Yes No Number & Type Irr Dom Pub <br /> S ` Score 5 Score S Score <br /> Distance to Well s) from 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) >100 51-100 S 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None 01 Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems,.water wells, ponds) None `� Unknown Present <br /> Unique site features: Recharge area, coarse sail, nearby wells. At least More than <br /> -.t <br /> xxxxxx None 01 one one <br /> COLUMN TOTALS»>TOTAL POINTS + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 48 pts 40 pts or less <br /> I <br /> gQ/1?3,� B T XJ E B X EMAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 505 .3 I.T <br /> 3 1. 1. NA\3 <br /> Sample Result GASOLINE 1000 100 10 i <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not ete 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. I ppm (diesel). <br /> \3 Levels for BTX&E are not applicable at'a TPH concentration of 10 (gasoline) or 100 <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels FYesl Ho <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 /> CORCUR WITH STAFF RECOMMENDATIONJOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAELED J / <br /> NAME OF i <br /> EVALUATOR <br /> I 11 a LIN <br /> L_ - I Y---j <br /> EH 2380 (UGTWKSHT)\5/90 <br /> � I <br />