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SAN JOAoIN 100PU61111 HEALTH SERVICES/ENVIRONMENTAL HEALT VISION <br /> I. WORKSHEET FOR SITE CLOSURE EVALUATION W, DATE <br /> NAME OF FACILITY _J_J '__y SWEEPS CODE A3j <br /> ADORESS ' TANK 10 B - <br /> TANK SIZE FUEL TYPE' <br /> II. GENERAL SITE HISTORY <br /> ttt <br /> Is permit current? Yes No Permit 0 Facility Status Code Doc.Soit/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes mHo Failed precision test ? Yes No If yes, give date(s) 1A Q,- <br /> Was <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? j i 3— <br /> d e <br /> Was repair done under inspection? Yes !kwer* soil sampples analyzed? Yes No BTXBTPN-G TPH-0 Pb/EDB6 <br /> Type of failure/discharge catastrophicerm leakage ovecfitl unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION WORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Solt Samples Received Yes No Depth to Ground Water Ref/Year ; Average Annual Precipitation As 14 10-25 <br /> Orn-Site Wetl(s) Yes No Neuter3r=ypel <br /> rr Dom Pub <br /> S Score S Score S Score <br /> Distance to Welt(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 ant E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) 2,100 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 xx== 26-40\2 <br /> Man-made conduits which increase nicat migration <br /> of leachate (i.e., septic system, water welts, ) MGM Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby watts. At least Nor* than <br /> xXXxxX Now orfs one <br /> COLUMN TOTALS»>TOTAL POINTS + + s <br /> Sample Result: (B T X OR E) RANGE Of TOTAL POINTS 49 pts or more 41 - 4$ pts 40 pts or less <br /> B T XE B T X E <br /> MAXIMUM ALLWBLE 3-T•X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPN DIESEL 10,000 1000 100 <br /> FOOTNOTES: t'*If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.*., site is currently on UGT Contamination list for soft or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <s5 ft., do not use Cable. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for STX3E are not appticobte at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX b E or TPN Concentrations > Attowabte Lents *Yes No <br /> 2. Recommmid Site Closure Yes Mo If Yes, Refer to Site Mitigation for Evacuation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CCNCJR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FON EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTNKSHT)\5/90 <br />