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SAN JOIAQUIN COU'" PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALAISION <br /> I, l%.)WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY D5 I vjo SWEEPS CODE RZ 3 1;7411 <br /> ADDRESS dyX,,P1D� 9L TANK ID 0 0� <br /> TANK SIZE FUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? Yes No VPermit 0 - Facility Status Code / Ooc.SOil/GLI Cont Yes Na <br /> Number of Tanks at facility Age of Tanks(if available) _ is Type of Tank Steel Fbrgi Sngi Dual <br /> III. TANK HISTORY 5iPAU• <br /> was Tank tested? Yes I IN01 Failed precision tea 7 Yes No If•yes, give dates) <br /> was a repair made to the tank system? Yes No[v If yes, what was repaired? <br /> Was repair done under inspection? Yes No were sail samples analyzed? Yes NoBTXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INS ECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Yater Ref/Yearr -66 Average Annual Precipitation A-114 10-25 <br /> On-Site Welts) Yes No Humber 8 Type Irr Dao Pub <br /> 5 Scare 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)'IJ.35"-JD,ZC >100 51-100 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 ie ?s. At least More than s. <br /> XoC= None one [�orne <br /> » <br /> COLUMN TOTALS >TOTAL POINTS + 3� t f 1 <br /> Sample esult: (8 T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> IT 4E-N •ia <br /> B T X E B T X E <br /> V� �-' '3 fT'V% MAXIMUM ALLOWABLE a-T-X-E LEVELS (PPM) 1 50 SO 50 .3 .3 1. 1_ NA\3 <br /> Sample Result: GASOLINE 1009 100 10 <br /> MAXIMUM ALLOWMLE TPH LEVELS (PPM) <br /> OIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented sail and/or grolafd water contamination is present, do not complete the Leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for sail or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points_ If depth �c_-5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points, <br /> \3 Levels for STX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF iECOMMENDATION/CONCLUSION a iYne' <br /> 1_ Are BTX 8 E or TPH Concentrate > Le Levels *Yes a <br /> [arid� <br /> 2. Recommend Site Closure Yes No If Y er tJ <br /> o Site Mitigation for Evaluation �/1 �"r *D U-5- <br /> V11. <br /> 5.V11. REVIEW EVALUATION - TO BE COMPL SUPERVISOR/SENXOR <br /> CONCUR WITH STAFF RECCMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NQ <br /> DATE REFERRED / / DATE CLOSURE LETTER NAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />