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SAN JOAQUINY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA IVISION <br /> I ST WORKSHEET FOR SITE CLOSURE EVALUATION DATE( <br /> NAME OF FACILITY SWEEPS CODE( <br /> ADDRESS6 ITANK ID X <br /> TANK SIZE IFUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit # - Facility Status Code DOc.SOiL/GW Coni Yes INo <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No if yes, give date(s) <br /> Was a repair made to the tank system?IYes No If yes, what Was repaired? <br /> I Was repair done under inspection? Yes NcI (Were soil samples am Lyzed?�Yes No BTXE ITPH-GI ITPH-0 IJ <br /> Pb/EDB <br /> �Tvpe of failure/discharge catastrophic long-tens leakage Iaverfill (unknown (other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Waterl (Ref/Year (Average Annual Precipitation A= 14 10-25 <br /> On-Site Weil(s) Yes No Number & Typej. Irrl Dam Pub S ScoreS Score S Store <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 is met E is met E is met <br /> Minimum Depth to groundwater from the Sail Sample (feet) >100 I51-100 ( 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) I None I ! Unknown (Present <br /> Average Annual Precipitation (inches) XXxxxxj <10 9 10-15 Ixxxxxxxl 26-40\2 <br /> Man-Made conduits which increase vertical migration t I None I Unknown Present <br /> of leachate (i.e., septic systems, water wells, panels) <br /> Unique site features: Recharge area, coarse soil, nearby wells. At Least More than <br /> XxxxxX More one �y" one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> t <br /> Sample Result: (S T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts I 40 pis or less <br /> B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1I 50 50 SO .3 .3 , 1. NA\3 <br /> Sample Reyyyyx GASOLINE 1000 700 10 <br /> s <br /> �/� Y �t MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPM DIESEL 10,000 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 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 O points. <br /> \3 Levels for STX&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 ('Yes (NoI <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/S IOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE IYES I• NOI IREFERRED TO SITE MITIGATION FOR EVALUATIONIYES NO� <br /> DATE REFERRED Z4 f2_Q (DATE CLOSWRE LETTER MAILED( <br /> NAME OF <br /> EVALUATOR Ill <br /> EH 23 80 (UGTWKSHT)\5/90 <br />