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SAN JOAQU*NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL�TH DIVISION <br />1. GST WORKSHEET FOR SITE CLOSURE EVALUAT10 DATE <br />NAME OF FACILITYt� SWEEPS CODE a 31111 <br />ADDRESS 5 TANK ID Al, i 1 / 0 <br />!TANK SIZE / Q p� ® !FUEL TYPE v <br />II. GENERAL SITE HISTORY <br />FIs permit current?(Yes INo y (Permit Facility Status Code 0 �Doc.Soil/GW Cont Yes Nol <br />!Number of Tanks at facility! / Age of Tanks(if available) Type of Tank Steel 1xiFbrgl! Sngl Dual <br />III. TANK HISTORY <br />;Was Tank tested? (Yes NoI Failed precision test ? Yes Nol If yes, give date(s) <br />;Was a repair made to the tank system? Yes , to If yes, what was repaired?1 <br />!Was repair done under inspection? Yes �N"� Were soil samples analyzed? Yes! (NoI BTXE) TPH-G+ TPN -0` Pb/EJB( <br />Type of failure/discharge! catastrophic !long-term leakage) `overfill unknown) other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />jSoil Samples Received Yes1 NoI `Depth to Ground Water *I Depth (Average Annual PrecipitationlA=114 110-25 <br />On -Site Well(s) Yes No! INumber & Typ�,Irr Dom! IPubl I I <br />S Score S`l Score S Score <br />Distance to Well(S) from Tank! ;2- ft; �ft; ft C 10 pts C 9 pts C 5 pts <br />'Man -Made conduits which increase vertical migration <br />�of leachate (i.e., septic systems, water wells, ponds) %� (,�% 5 I Norte <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />xxxxxxl None <br />Unknown I (Present <br />At least! I More than <br />oneone <br />IRI= rsI+ -arO N'kfihawo _ oao <br />CUMOT0 - jig /0 1_3�t S TBA 0. O,Aj j� <br />(Semple Res Lt: (3 T X OR E) RANGE OF TOTAL POINTS 49 pts or more 1 41 - 48 pts 1 40 pts or less ! <br />Il 'MAXIMUM ALLOWABLE 8 -T -X -E LEVELS (PPM) 11 50I 50 50 I .3 I.3 1. 1. NA\3 <br />Sample Result: GASOLINE 1000 ! 100 10 <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />TPN G� DIESEL 10,000 ( 1000 ! 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 on 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 )41 a4l,&ej <br />1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No r a� / 1 /v <br />1...� <br />2. Recommend Site Closure Yesl No *If Yes, Refer to Site Mitigation Evaluation <br />f►1T B � � , 3.� <br />VII. REVIEW EVALUATION - TO SE COMPLETED BY A SUPERVISOR/SENIOR o <br />CONCUR WITH STAFF RECCMMEYDATION FOR CLOSUREIYES 1NO1 (REFERRED TO SITE MITIGATION FOR EVALUATIONIYES <No <br />I 1 <br />DATE REFERREDI DATE CLOSURE LETTER MAILED i <br />NAME OF <br />EVALUATOR Iv. _ <br />:n cj au luut*Kan i!\.j/7a <br />0 <br />if <br />0 <br />if <br />0 <br />if <br />R <br />E <br />condition <br />is met <br />R <br />E <br />condition <br />is met <br />R <br />E <br />condition <br />is met <br />V. Site Feature - Leaching Potential Analysis <br />Minimum Depth to groundwater from the Soil Sample (feet) q6_13 <br />I >100 <br />I E51-100 <br />I <br />( 25-50\1 <br />;Fractures in subsurface (applies to foothills or mountain areas) <br />1 <br />I None <br />! I Unknown j <br />!Present <br />!Average Annual Precipitation (inches) <br />xx,,, <br /><10 <br />1 9 <br />1 10-25 fxxxxxm1 <br />26-40\2 ! <br />'Man -Made conduits which increase vertical migration <br />�of leachate (i.e., septic systems, water wells, ponds) %� (,�% 5 I Norte <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />xxxxxxl None <br />Unknown I (Present <br />At least! I More than <br />oneone <br />IRI= rsI+ -arO N'kfihawo _ oao <br />CUMOT0 - jig /0 1_3�t S TBA 0. O,Aj j� <br />(Semple Res Lt: (3 T X OR E) RANGE OF TOTAL POINTS 49 pts or more 1 41 - 48 pts 1 40 pts or less ! <br />Il 'MAXIMUM ALLOWABLE 8 -T -X -E LEVELS (PPM) 11 50I 50 50 I .3 I.3 1. 1. NA\3 <br />Sample Result: GASOLINE 1000 ! 100 10 <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />TPN G� DIESEL 10,000 ( 1000 ! 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 on 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 )41 a4l,&ej <br />1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No r a� / 1 /v <br />1...� <br />2. Recommend Site Closure Yesl No *If Yes, Refer to Site Mitigation Evaluation <br />f►1T B � � , 3.� <br />VII. REVIEW EVALUATION - TO SE COMPLETED BY A SUPERVISOR/SENIOR o <br />CONCUR WITH STAFF RECCMMEYDATION FOR CLOSUREIYES 1NO1 (REFERRED TO SITE MITIGATION FOR EVALUATIONIYES <No <br />I 1 <br />DATE REFERREDI DATE CLOSURE LETTER MAILED i <br />NAME OF <br />EVALUATOR Iv. _ <br />:n cj au luut*Kan i!\.j/7a <br />