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SAN JOAQUT INTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL i4 'H DIVISION <br /> JGST WORKSHEET FOR SITE CLOSURE EVALUATI DATE 7 <br /> NAME OF FACILITY [a r S r <br /> / l SWEEPS CODE <br /> ADDRESS f�T` TANK,14 ,Y ID # <br /> 1 ? <br /> TANK SIZE FUEL TYPE � ' ! � e S <br /> a II. GENERAL SITE HISTORY S �� <br /> Is permit current? *** <br /> P Yes No Permit # HofTanksH(if <br /> Facility Code Doc.Soil/GW Cont Yes Na <br /> Number of Tanks at facility Agvailable) { Type of Tank Steel Fbr9L sng[ Dua€ <br /> i III. TANK HISTORY <br /> i <br /> Was Tank tested? Yes No Failed precision test ? Yes No If Yes,, gi.ve date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No STXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic Long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOyLEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water r Ref/Year Average Annual Precipitation A= 14 10-25 <br /> On-Site Well(s) Yes No Number & Type Irr Dom Pub <br /> S Score S Score 5 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 <br /> To <br /> R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is it <br /> E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) >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 70-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of Leachate (i.e., septic systems, water wells, ponds) None unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At Least More than <br /> xxxxxx Harte one one <br /> COLUMN TOTALS>>>TOTAL POINTS + + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more - 411 pts 40 pts or Less <br /> SPI - P 1 •'UD <br /> , � �� B T ¢x E.4 B T x E <br /> 4Z MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 X50 50 .3 J.3 1. 1. NA\3 <br /> Sample Res. lt: GASOLINE 1000 100 10 <br /> P j % N f / MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 'a 5 TPH D DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground Nater contamination is present, 'do at c 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 *Yes No �� _D S�w r�"r' O YL c� <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 YESNQ REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED L-\�/ ` .� / Ci DATE CLOSURE LETTER MAILED <br /> NAME OF r <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />