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SAN JOAQUIN COU1l����iU8LIC HEALTH SERVICES/ENVIRONMENTAL HEAL! YISION <br /> UCST"WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> ' f`FACILITY ' SWEEPS CODE <br /> L� 803 <br /> ;ss ' � TANx ID <br /> AK SIZE 1.1:560 FUEL TYPE j 7l1NK�lfi W <br /> _ 3- 1-9� <br /> GENERAL SI E HISTORY <br /> tut <br /> [s permit current? Yes No Permit it - Facility Status Code Doc.Soil/GW Cont YesNo <br /> Number of Tanks at facility Age of Tanks(If available) ` Type of Tank Steel Fbrgl Sngl Dual <br />::I. TANK HISTORY <br /> Was Tsnk tested? Yes No Failed precision test 7 Yes Na If yes, give date(s) <br /> Was a repair made to the tank system? Yes No xiIf yes, what was repaired? <br /> Was repair done under inspection? YesNo were salt samples analyzed? Yes No BTXE TPH-G TPH-0 Pb/EDB <br /> Type of failure/discharge catastrophic Long-term leakage overfill unknown other: <br />:'1, REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> 'aiL Samples Received Yes No Depth to Ground Water z1bRef/Year Average Annual Precipitation A= 14 10-25 <br /> :n-Site WeIL(s) Yes No Number & Type Iry Dam Pub <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 /> N. Site Feature - Leaching Potential Analysis E is met ' E is met E is met <br /> 'Minimum Depth to groundwater from the Soil Sample (feet)— (+ '.100 W10_25 <br /> 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas)' None Present <br /> Average Annual Precipitation (inches) xxxxxx c10 4 xxxxxxx 24-40\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 soft, nearby wells. At Least Have than <br /> Ce M e•rt�' tan %:4 xxxxxx None ane one <br /> .� COLUMN TOTALS»>TOTAL POINTS + F <br /> r <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 48 pts 1�r40 pfs or Tess <br /> + B T X E B IT x E <br /> -.h�(� = • '��� MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 14 NA\3 <br /> S le R suit- GASOLINE 1000 100 10 <br /> `rr r 3 oO H D MAXIMUM ALLOWABLE TAH LEVELS (PPM) DIESEL 10,000 1000 100 f <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the teaching-_0 5J <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 4c--5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, scare 0 points. `" <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />(I. STAFF "iECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Cancentrations > Allowable Levels *Yes No 3- <br /> 2. Recaneaend Site Closure Yes Na If Yes, Refer to Site Mitigation for Evaluation LTO - <br /> F11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/ ENIOR <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 /> E OF <br /> UA70R <br /> 80 (UGTWKSHT)\5/90 <br />