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SAN JOACUIN C Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL 4U IVISION <br /> Y. <br /> WORKSHEET FOR SITE CLOSURE -eVALUATION DATE( I.? <br /> IMAMS OF FACILITY I 7 ` IsWE�PS CODE I 6) 4 I <br /> (ADDRESS ITANK ID ;91-3 7 - 1 7 V� — II <br /> TANK SIZE FUEL TYPE <br /> [I. GENERAL SITE HISTORY <br /> Is permit current? Yes rNO� Permit Facility Status Codef Doc_SoiL/GS1 ContYeNo <br /> Numoer of Tanks at faciLityl (Age of Tanks(if avaiLabLe)I (Type of Tank lSt=LFbgl ISngl Duat <br /> Ii_ TANK HISTORY II ® D v � 7yf�yu'fJ <br /> Was Tank tested?(Yes No� IFaiied precision test ?1YesI �Na if yes, give date(s) / ! / / -fG <br /> Was a repair made to the tank sysrem?IYes I Nof If yes., what Was repaired?( N O 'Ja �' <br /> Was repair done under inspection?IYes I No� Were soil samples analyzed?',(Yes b<1No{ STXEJ jTPH-G ITPH-D I IPb/EDaI r <br /> Type of failure/discharge) catastrophic long-[erm Leakage overfill unknown other: ��- <br /> i <br /> 'V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> lSoiL Samples Received Iyes l Na (Depth to Ground Water Ref/Yearl g ; (Average Annual PrecipitationlA= 14 10-25 <br /> Ii On-Site Well(s) Yes �No (Number & Type �Irrl Dom IPubI <br /> S Scare S Score S Scare <br /> Distance to Wells) from Tankl ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> O I if O if O if <br /> R condition R condition R condition <br /> ;V. Site Feature - Leaching Potential Analysis -c is suet E is met c is met <br /> IMinimum Depth to groundwater from the SoiL Sample (feet) .� I >10O I51-100 I 125-50\1 <br /> ,Fractures in subsurface (applies to foothills or mountain areas) Nane I I Unknown l Present I <br /> !Average Annual Precipitation (inches) ,xxxxxxl <10 1 9 110-25 Ixxxxxxxl 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> Iof leachate (i.e., septic systems, water weLLs, ponds) None I Unknown I ,Present <br /> ,Unique site features: Recharge area, coarse soil, nearty wells. I I At Least More Chan <br /> xxxx= None 1 one one <br /> I <br /> COLUMN TOTALS»)TOTAL POINTS <br /> Sample Resuit: (S T X OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 - 48 pts 40 pts or less <br /> MAXIMUIM ALLOWABLE 3-T-X-E LEVELS CPPM) 11 50 50I 5 .3JT 11 11.1 1_ NA\3 <br /> jSamole Result;. GASOLINE .1000 I 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 I 1000 100 <br /> FOOTNOTES: **"If documented soil and/or ground water contamination is present, do not complete the Leming potential <br /> analysis. (f-e., site is currenrly on UGT Contamination List for saiL or ground water.) <br /> \i 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 3TX&E are not appiicabie at a TPH concentration of 10 ppm (gasoLine) or 100 ppm (diesel). <br /> :. STAFF RECOMMENDATION/CONCLUSION <br /> i. Are 3TX die or TPH Concentrations > ALLowabie Levels *Yes INa <br /> Z. Recommend Site CtosureIYes l No If Yes, Refer to Site Mitigation for Evaluation <br /> :I. REVIEW EVALUATION - TO BE COMPLETED 3Y A SUPERVISOR/SENIOR ! <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES INOI REFERRED To SITE MITIGATION FOR `VALUATIONIYESI INOI I <br /> DATE .REFERREDI I DATE CLOSURE LETTER MAID( LI <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />