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- SAN JOACUIN COU ELIC HEALTH SERVICES/EVVIRONMERTAL HE:ALT <br /> N COU <br /> ATE 1� c�d D <br /> UC_ SHEET FOR SITE CLOSURE EVALUATION D <br /> SWEEPS CODE <br /> NAME OF TANY 101# <br /> ADDRESS 2 S- 7-5'- <br /> TANK SIZE / O ad FUEL TYPE <br /> [. GENERAL SITE HISTORY poc,Soil/GV Con Ye No <br /> No Permit I fta23 /Q?� Facility Status Code SZ <br /> Is permit current? es / Sngt Dua <br /> Hurber of Tanks at facility <br /> Age of Tanks(if available) 9 7 -Type of Tank Sleet Fbrg <br /> :It. 7AH7C HISTORY <br /> Yes No Failed precision test ? Yes <br /> No if yes, gi <br /> Was Tank tested? ve <br /> iwas a repair mode to the tank syste�t YGs <br /> No If yes, what was repaired? <br /> Was repair done under inspection? Yes <br /> No were soil saaples analyzed? Yes Ho BTXE TPH-G TPH-D Pb/EDB <br /> - <br /> Type of failure/discharge catastroFhic long-tern leakage overfill <br /> other: <br /> AL <br /> IV. REMOVAL HISTORY {ATTACH INSPECTICN REPC2T FOR SITE DETAILS/COCl CT Average A A F LEACHING POTENT IAry�aAxAi`KS ANALYSIS) <br /> A- 14 10-25 <br /> Soft Samples Receiv Yes No Depth to Groutii Vater Ref/Year i <br /> No Nu:ber I Type 7 Irr Dom Pub S Score S Score <br /> Cn-Site WellCs Yti 5 Score C 9 pts C 5 pts <br /> _ft; _ft; ft C 10 pts 0 if o_ if <br /> Distance to Vel s) from Tank 0 if condition <br /> R condition R condition R <br /> E is met <br /> Mini== Depth to grounL'�+ E is mat <br /> E is met <br /> V. Site Feature - Leaching Potential Analysis >100 is met 25'50\1 <br /> ater from the Soil Seaple (feet) <br /> I <br /> 100 <br /> x or:e Present <br /> Fractures in subsurface (applies to foothills or mxntain areas} -/ Unknown <br /> <10 9 10-25 26-40\2 <br /> (inches) <br /> Average Armal Precipitation <br /> e cX xxxxxxx <br /> Man-Made cerduits which Is,sreas�veya`�lwelIs, pis) <br /> None U ,n S (Present <br /> of leachate (i.e., septicYs At least More than <br /> wells. one one <br /> Unique site features: Recharge area, coarse soil, nearby xxxxxX Hone <br /> Is - 16 z8 <br /> COLUMN TOTALS»>TOTAL POINTS 41 - 48 pts 40 pts or Less <br /> RAga OF TOTAL POINTS 49 pts or more <br /> Sample Result: (3 T X OR E) B T X E a T X E <br /> NA\3 <br /> WIMI.?1 ALLOWABLE 3-T-X-E LEVELS (PPM) 1 50� 50I 50 .3 .3 1. 1. \ <br /> GASOLINE 1000 <br /> 100 10 <br /> Saapte Result: iyAXI" ALLOWABLE TPH LEVELS (PPM) 1000 100 <br /> DIESEL 10,CC0 <br /> 20 dOD TPH lata the leaching potential <br /> water contamination is present, do not comp <br /> FOOTNOTES: *"If documented soft andlor gra on UGT Contamination List far sail or 9ra� water.) <br /> analysis. (1.e., Site fs cur Or*l0 points. If depth --5 ft., do not use table. <br /> 25 sc <br /> \1 If depth is > 5 ft. a 40 inchas,�score 0 points. (gasoline) or 100 ppm <br /> Cdiesel). <br /> If precipitation is applicable at a TPH concentration of 10 X= (4 <br /> \3 Levels for 3TXbE are not app <br /> VI. STAFF RECcmKENDATICN/CONCLUSICN <br /> 1. Are BTX b E or TPH Coneentratioees <br /> > Allowable Levels 'Yes No <br /> 2. Recommend Site Closure Yes No <br /> If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATICN - TO Be COMPLETED ay A SUPERVISCR/SENIOR <br /> YOATICN FCft CLC9.lRE TES NO REFERRED TO SITE MITIGAT[C1i FOR EVALUATION YES NO <br /> CONCJR WITH STAFF 2ECCVMtE• <br /> / DATE CLOSURE LETTER MAILED <br /> DATE REFERRED <br /> NAME OF <br /> EVALUATOR . <br /> EH 23 80 (UGTVXSHT)\5/90 <br />