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SAN JCAOUIN IN TY PUBLIC HEALTH S'cRVICES/ENVIRONMENTAL H "'H DIVISION <br /> i. ST WORKSHEET FOR SITE CLOSURE EVALUATION DATE( <br /> NAME Of FACILITY M cu SWEEPS CODE <br /> ADDRESS 3 U ,'� -T'rCL:. �U rk (TANK ID 91 - <br /> TANK SIZE ki IFUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current?(Yes No Permit if - (Facility Status Code IDoc.Soil/GW Contll I <br /> Yes <br /> Number of Tanks at facility Age of Tanks(if available) C Ik (Type of 'rank ISteel 1N Fbrgt Sngt� Dual <br /> III. TANK HISTORY <br /> Was rank tested? Yes / No Failed precision test ? Yes No IIf yes, give date(s)I <br /> Was a repair made to the tank system? Yes No IIf yes, what was repaired?I <br /> Was repair done under inspection?I Yes 11 No) Were soil samples analyzed? Yesl No STXE TPH-G TPH-0 Pb/EDB <br /> I I <br /> Type of failure/discharge) catastrophic long-terns leakage IoverfiLLI (unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes )( INoI Depth to Ground Water <br /> IRef/Year ; Average Annual Precipitation IA3 14 10-25 <br /> On-Site Wetl(s)IYes No (Number & Type) Irr (Dom iPub) <br /> S Scare S Scare S Scare <br /> Distance to Welts) from Tanki 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) ' >100 1 151-100 I 125-50\1 <br /> (Fractures in subsurface (applies to foothills or mountain areas) i Norte I I Unknown I 5 (Present <br /> iAverage Annual Precipitation (inches) �xxxxxxl <10 1 9 1 10-25 Ixxxxxxxl 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None I Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. I At least! (More than <br /> lxxm=l None I onelj J one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> Sample Result: (3 T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 1 40 pts or less <br /> L r' MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 11 50I 50I 50 I .3 J. <br /> 1.1 <br /> 1. I MA\3 <br /> Sample Result_" GASOLINE 1000 I 100 I 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> hi D__ DIESEL 10,000 I 1000 I 100 <br /> FOOTNOTES: *"If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently an 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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are 8TX & E or TPM Concentrations > Allowable Levels *Yes) 7177 <br /> 2. Recommend Site Closure Yes No � If Yes, Refer to Site Mitigation for Evacuation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYESI NOi iRErFEERRED TO SITE MITIGATION FOR EVALUATIONIYESI INO! I <br /> DATE REFERRED) / / (DATE CLOSURE LETTER MAILED( <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />