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4 SAN JOAQUIN COUUBLIC HEALTH SERVICES/ENVIRaNMENTAL �HEALTif I'll SION <br /> UG;WORKSHEET FOR SITE CLOSURE EVALUATION! �1�/ DATE z <br /> l SWEEPS CODE <br /> •NAME OF FACILITY <br /> s l� • ITA)1K ID 0 <br /> ADDRESS( <br /> TANK SIZE FUEL TYPE <br /> i II. GENERAL SITE HISTORY <br /> No (Permit 9 - Facility Status Code ' Doc.SoiL/GW Cont Yes No <br /> is permit current? Yes <br /> Number of Tanks at facility <br /> Age of Tanks(if available) 7yp�ofTank SteelFbrg[ Sngl Dual <br /> f Ili. TANK HISTORY <br /> dive date(s) <br /> Rafkfested? Yes No Failed precision test ? Yes No If yes, g <br /> r ,Wade to the tank system? Yes No If yes, what was repaired?done under inspection? Yes No Weresoil samples analyzed? Yes } NoBTXETPH-G (TPH-Dlure/discharge catastrophic long-term leakage overfill unknown other: <br /> } <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> h Soil Samples Received Yes No Depth to Ground Water Ref/Year <br /> �1 Average Annual Precipitation A= 14 10-25 <br /> on-Site WeM s) Yes NO Number & Type Irr Dom Pub ;{ . <br /> S Score S Score S Score <br /> Distance to We[l(s) from Tank ft; ft; ft C 10 pts C 9 pts CO 5fpts <br /> 0 if I� 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching potential Analysis E is r1. E is met E is met <br /> . <br /> >100 I, 51'i40 S 25-50\1 <br /> Minimum Depth to groundwater from the Soil Sample (feet) , <br /> Hone Unknown Present� ,' I <br /> Fractures in subsurface (applies to foothills or mountain areas) /4 ,r <br /> Average Annual Precipitation (inches) xx <br /> xxxxxx1 <10 9 10-25 xxxux26-40\2 <br /> iMan-Made conduits which increase vertical migration /0 N°ne Unknown Present <br /> of leachate (i.e., septic systems, water weLLs, ponds) <br /> Ia At Least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None G(�' one one <br /> S' y3 <br /> COLUMN TOTALS»>TOTAL POINTS' <br /> Sample Result: (B T X OR E} RANGE OF TOTAL POINTS 49 pts or more I, <br /> 41 - 48 pts I 40 pts or less <br /> NO �� B T Xf E 8 JT X.1 E <br /> 'r . t3 3 y MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 I <br /> I .3 .3 11. NA\3 <br /> GASOLINE 10001 100 10 <br /> Sample Result: <br /> f7 MAXIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL 10,004 1000 100 <br /> TPH <br /> FOOTNOTES ***If documented soil and/or ground water contamination is present, do'n°t complete the leaching potential <br /> analysis. (i.e., site is currently on UGT C°ntaarinati5 ftst,,dornatilusertabie.� water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. if depth �t <br /> \2 If precipitation is > 40 inches, score 0 points. asoline) or tO0 ppm (diesel). <br /> I \3 Levels for BTX&E are not applicable at a TPH cencenttatian of 10 ppm C9 <br /> VI. STAFF RECOMMENDATION/CONCLUSION j[ ,jam r�Vl l� <br /> 1. Are BTX & E or TPH Concentrations > Attowable Levels *Yes No I <br /> 2. Recommerxi Site Closure Yes No if Yes, Refer to .Site Mitigation fJbr Evaluation <br /> YlE. REVIEW EVALUATION - TO BE COMPLETED 8Y A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES HO (REFERRED TO SITE MI`IGA7ION FOR EVALUATION YE5 NO� <br /> f DATE,CLOSURE LETTER MAILED �i / <br /> DATE REFERRED <br /> NAME of <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90. J , ; ; _ �'}� <br /> _RG3 .M5:Y . <br />