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SAN JOAOUIN ^OT <br /> Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HV' 4 DIVISION <br /> I, WORKSHEET FOR SITE CLOSURE EVALUATION DATE 7-3— <br /> NAME OF FACILITY �h��JQJ �� ,� SWEEPS CODE ;�,3 15, 7z' <br /> ADDRESS 6)0 L— TANK [D $1 / 15 7C/G_ 3 <br /> TANK SIZE la 600 FUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit - `Facility Status Code ( — Dac.SaiC/GW Cant les No <br /> Number of Tanks at facility Age of Tanks(if available)I (Type of TankISteel Fbrgl Sngll Dual) <br /> III. TANK HISTORY <br /> Was Tank tested? Yes FX N70F <br /> Failed precision test ?IYesI No If yes, give dates) <br /> Was a repair made to the tank system? Yesl No IIf yes, what was repaired?I�I& , 01, t <br /> 11 cif- t4-1 <br /> fe- <br /> Was repair done under inspection?I 1 ,NYes No Were soil samples analyzed?IYes No BTXE JTPH-G TPH-DI Pb/EDB, <br /> Type of failure/discharge catastrophic long-term leakage) overfill) )unknown ot{�ter• 'i' 'V'O�/P <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANA& S S)I <br /> Soil Samples Received Yes No Depth to Ground WaterRef/Yearlg� Average Annual Precipitation`A= 14 110-25 <br /> IOn-Sit e Well(s)IYes INo Number & Type jIrr Dam, Pub <br /> S Score S Scare S Score <br /> Distance to WeLL(S) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet)0 ' >100 ` I51-100 I 5 ! 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) ! one Unknown I IPresent <br /> Average Annual Precipitation (inches) xxxxxxI <10 9 1 10-25 Ixxxxxxxi 25-40\2 <br /> Man-Made conduits which increase vertical migration 5 o Leachate (i.e., septic systems, water wells, ponds) I None Unknown IPresent <br /> Unique site features: Recharge area, coarse soil, nearby wells_ At least More than <br /> =o= None I one one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 - 4$ pts pts or less <br /> B T I X I E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1' 50) 50' 50 .3 1.3 , 1 . 1 NA\3 <br /> Sample Result-• GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1 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 <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels I*Yesl No <br /> 2. Recommend Site Closure Yes No if Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE Y£SI INO! (REFERRED TO SITE MITIGATION FOR EVALUATION YES INOI , <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILS <br /> NAME OF <br /> EVALUATOR <br /> =H 23 80 (UGTWKSHT)\5/90 <br />