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SAN JOAQUIN CC PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL-IN, LVISION <br /> WORKSHEETj FOR SITE CLOSURE EVALUATION " .' DATE <br /> /ME OF FACILITY D SWEEPS CODE <br /> L iq! ! _ <br /> DRESS 5 D O ` ' TANK ID B C l <br /> 72 7- <br /> TANK SIZE ,���� FUEL TYPE Q! <br /> It. GENERAL SITE HISTORY <br /> Is permit current? Yes Na Permit Facility Status Code Q! Doc.Soil/GW Cont Yes Ito k <br /> Number of Tanks at feeility f Age of!'Tanks(if available) Type`of Tank Steel Fbrgl Sngl DuaL 1! <br /> I11. TANK HISTORY II E <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? Yes No BTXE TPN-G TPH-D Pb/EDB y <br /> type of failure/discharge catastrophic long-term leakage overfill unknown other: M <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> S <br /> Soil Samples Received Yes No Depth to Ground Water 5 a Ref/Yea �� Average Annual Precipitation A= 14 10-25 <br /> On-Site Well(s) Yes No Number & Type Irr 'k Dom Pub 1 <br /> S Score' S 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 i(feet> 5d >100 51-100 _i5 25-50\1 <br /> Fractures in subsurface (applies to foothilLs or mountain areas). O None Unknown Present <br /> Average Annual Precipitation (inches) �� f 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 /> i <br /> Unique site features: Recharge area, coarse soli, nearby wells.' At least More than. 1 <br /> ! xxxxxx Hone one one # <br /> 1p � LI, <br /> COLUMN TOTALS>>>TOTAL POINTS i };! I O +� O� 7 + ° �� <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> Ail fi)D B T X EB JT E:. <br /> MAXIMIM ALLOWABLEiB-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3I,X1 <br /> 1. 1. HA\3 <br /> R <br /> Sample Result: GASOLINE 1000 100 10 <br /> 01 +p� MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or grotnd water contamination is present, do not complete the leaching potential . n <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) j <br /> T \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 9TX&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). f <br /> VI. STAFF RECOMMENDATION/CONCLUSIONLC <br /> fG. <br /> 1. Are BTX & E or TPH Ccneentratio%s > ALLowabU6 Levels .*Yes !; Ha Da- j <br /> � � <br /> 2. Recommend Site Closure YesNo If Yes, Refer to Site Mitigation for Evaluation <br /> a <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 EVALUATIONYES NO <br /> SATE REFERRED /� / DATE CLOSURE LETTER MAILED <br /> NAME OF F I <br /> EVALUATOR � f'^� J <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> C47-% <br />