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SAN JCACUIN COUNTY "LIC HEALTH SERVICES/ENVIRCNNE4TAL 4EALTH 0' ICH <br /> UGST LORXSHEET FOR SITE CLOSURE V/ALUATICH DATE <br /> ' CF FACILITY L(.1id/ IlJ (SWEEPS CODE <br /> i .R°SSI /cJ TANK ID 3 -�� <br /> A:X s;z=_ISSD (FUEL v£ Jr�soC e. Re SGiwl ie_ ali-f 2V fi8 <br /> GEIERAL SITE HISTORY <br /> xrmit current7IYes No Permit Y Facility Status Code Dec.sail/Gw ContlYes No <br /> ;Teter of Tanks at facility) r (Age of Tanks(if available) (Type of Tankl Steell IFbrgll ISngll Ouall <br /> TANK HISTORY <br /> J <br /> 3s Tank nes:ed7 l7esl NoI Failed precision test 7 Yesl No If yes, give date(s) <br /> as a repair made to the tank system? Yesl No x <br /> If yes, what was repaired7l <br /> is repair done under inspection? Yes INoI I <br /> were soil samples analyzed? Yes INoI BTX£ TPH-G ITPH-01 IPb/5081 <br /> .re of failure/discharge catastrophic •I long-term leakage) (overfill U*nam other: <br /> �REMCVAL 41STCRY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ;nil Saaptes Received Yes xi <br /> No Depth to Grand Waterb 6IRef/Yearlg'( ; Average Am t Precipitation)A-114 10-25 <br /> 'n-Site '4eLL(s)IYes No <br /> Number i type Err Dam IPubl <br /> S Score 5 Score 5 Score . <br /> ,istance to Wells) frac Tank a yY 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 /> Site Feature • Leaching Potential Analysis E is mac E is Mt £ is mac <br /> sinusm Oepth to groundwater frac the Soil Sample (feeU(J'Q—'r,,�;a 100 I I51-100 1 125-50\1 r <br /> Fractures in suesurface (applies to foothills or wt;ntain areas) I More I Unknown Present <br /> ^average Annual Precipitation (inches) szuzXxl <10 I 9 10-25 xxxxxxx 26-40\2 <br /> i <br /> *an-Made conduits which increase vertical migration r <br /> Unknown Present <br /> of Leaciate (i.e., septic system, water wells, ponds) Mone I <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least None than <br /> XXXxxz Nam one b e <br /> C.aan <br /> COLLM TOTALS>>>TOTAL POINTS l V I I i s3 r <br /> .Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or mro 1 41 - 48 pts I 40 pts or less <br /> (v'fpf/m Cz7e p B T X E B T X E <br /> X MAXIMUM ALLCWASLE 8-T-X-E LEVELS (PPM) 1 50 SOI .3 1. 1. <br /> ii= J <br /> �Sacple Result: <br /> GASOLINE 1000 100 10 <br /> 1 1) NAXINIaI ALLOWABLE iPN LEVELS (PPM) <br /> nvQ 10,000 1000 100 <br /> 7 TPN—Cl DIESEL <br /> FOOTNOTES: '"If doc mrted soft and/or ground water contami ration is present, do not eeaplete the leaching potential <br /> analysis. (i.e., site is currentty an 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 3TX8E are not applicable at a TPN concentration of 10 ppm (gasotine) or 100 ppm (diesel). <br /> VI. STAFF R£CCMMENDATION/CONCLUSION <br /> 1. Are 3TX i E or TPN Caw:entratioro > Allowable Levels 'Yes No <br /> 2 Recaimend Site Closure les No 'If Yes, Refer to site Mitigation for Evaluation) <br /> VII. REVIEW EVALUATION - TO 3E COMPLETED SY A SUPERVISOR/SENIOR <br /> CONC'R 'JI!M��7 <br /> FORYES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NOI <br /> -DATE REFEDATE CLOSER£ LETTER NAILEDNAME CF 'E`/ALUAICR /) y Vj� y' <br /> EH 23 d0 NGTWKSNT)\5/90 / ! le <br />