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SAN JOAQUIN CPUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA I&IVISION <br />1. T WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br />NAME OF FACILITY SWEEPS CODE <br />ADDRESS TANK ID # - <br />TANK SIZE FUEL TYPE <br />*** <br />permit current? Yes No Permit # - Facility Status Code Doc.SoiI/GW Cont Yes Nol <br />nber of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br />III. TANK HISTORY <br />Was Tank tested? <br />Yes <br />No <br />Failed precision test ? <br />Yes <br />Ref/Year <br />No <br />If <br />yes, give date(s) <br />14 <br />Was a repair made to the tank system? Yes No <br />If yes, what was repaired? <br />Yes <br />Was repair done under inspection? <br />YesNo <br />Were soil samples analyzed? <br />Yes <br />No <br />BTXE <br />Dom <br />TPH-G <br />Pub <br />TPH-D <br />Score <br />10 pts <br />if <br />condition <br />is met <br />Pb/EDB <br />Type of failure/discharge <br />S <br />C <br />0 <br />R <br />E <br />catastrophic <br />tang -term leakage <br />ft; ft; ft C <br />0 <br />overfill <br />V. Site Feature - Leaching Potential Analysis E <br />unknown <br />>100 <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received Yes <br />YES <br />No <br />Depth to Ground Water <br />YES <br />Ref/Year <br />; <br />Average Annual Precipitation <br />A= <br />14 <br />10-25 <br />On -Site Wells) <br />Yes <br />No <br />Nt er 8 Type <br />Irr <br />Dom <br />Pub <br />S <br />Score <br />10 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />9 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />5 pts <br />if <br />condition <br />is met <br />Distance to Well(S) from Tank <br />ft; ft; ft C <br />0 <br />R <br />V. Site Feature - Leaching Potential Analysis E <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />51-100 <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />Present <br />Average Annual Precipitation (inches) xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />Present <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />xxxxxx <br />None <br />At least <br />one <br />More than <br />one <br />COLUMN TOTALS>>>TOTAL POINTS <br />+ <br />+ <br />Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more <br />81 T X E <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 50 <br />41 - 48 pts <br />40 pts or less <br />B <br />.3 <br />JT <br />.3 <br />X <br />1. <br />E <br />1. <br />NA\3 <br />Sample Result: <br />TPN <br />GASOLINE <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />DIESEL <br />1000 <br />100 <br />10 <br />10,000 <br />1000 <br />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 8 E or TPH Concentrations > Allowable Levels *Yes 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 <br />YES <br />NO <br />REFERRED TO SITE MITIGATION FOR EVALUATION <br />YES <br />NO <br />DATE REFERRED <br />/ / <br />DATE CLOSURE LETTER MAILED <br />NAME OF <br />EVALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />