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SAN JOAQUIN Cd .PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALT' i;7ISION <br /> WORKSHEET FOR SITE CLOSURE EVALUATION �, DATE 7_ <br /> SWEEPS CODE NAME OF FACILITY 'A� J SLC '� 1J /� G��� r; �� �`3 <br /> ADDRESS Sic k' / d G <br /> TA 11 ID , - / / <br /> TYP <br /> TANK SIZE h_1�� FUEL E t sto ( �� �`- -- ` r K <br /> C �Flk� <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit it - Facility Status Code � � Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility 2 <br /> Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl 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 No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed?I Yes No BTXEI TPN-( WEDS <br /> Type of failure/discharge catastrophic long-term Leakage7l 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 Ref/Year Average Annual Precipitation A= 14 10-25 <br /> On-Site Wells) Yes No Number & Type Irr Dom Pub S Score S Score S Score <br /> Distance to Wells) 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)b_/S= >100 I51-100 5 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None 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 soil, nearby wells. At least More than <br /> xxmocx None one one <br /> COLUMN TOTALS?»TOTAL POINTS 10 1 Ig ( a .3ff <br /> Sample Result: (B T XX OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 - 48 pts 40 Pts or less <br /> -5 `K <br /> �� '�'� 7 �X 8 T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 3 .3 1_ 1_ MA\3 <br />{ <br /> Sample Result- 'rP14 GASOLINE 1000 100 10 <br /> Mlow ALLOWABLE TPH LEVELS (PPM) <br /> TPH a;I DIESEL 10,000 10100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not eoaQlete the teaching 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. <br /> \3 Levels for 8TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes12�_INo <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 /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED / <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> 1 <br />