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SAN JOADUIN CouvTv PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY 6 SWEEPS CODE <br /> ADORESS / �fj 0 TANK ID 9 - <br /> TANK SIZE FUEL TYPE <br /> It. GENERAL SITE HISTORY � � <br /> [s permit current? Yes No Permit 9 - IU /-� Facility Status Code C'gQgy*s <br /> eNo <br /> Nurber of Tanks at facility I remat Age of Tanks(if available) �- 11✓ _ Type of Tans Ste / / ,,� l Duo <br /> 111. TANK HISTORY '"� ' -f n i 7 '� wV t'� <br /> Was TanK tested? Yes No Faited precision test Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No if yes, what was repaired? <br /> IWas repair done under inspection? Tea No Were soil samples analyzed? Yes No BTXE TPN-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term Leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPEC ON REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Grand Vater /01 Ref/Year �` ; Ub Avereye Arcual Precipitation A- 14 10-25 <br /> On-Site weLL(s) Yes No Nurber 6 Type Irr Ow pub S Score S Score S Score <br /> Distance to Wells) frac Tank it; 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 Ata lysis E is net E is me[ E is met <br /> Minimae Depth to groundwater from the Soil Sade (feet) 9/Z-Ip-� >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) one Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxz 26-40\2 <br /> Man-Made conduits which increase vertical migration Present <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknown <br /> Unique site features: Recharge area, coarse soil, nearby welts. At Least More then <br /> xxxxxx None one one <br /> C011llM TOTALS»>TOTAL POINTS + + <br /> Sade Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> flTX E B T X E <br /> MAXIMLM( ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sasple Result: �DISESEL <br /> OLINE 1000 100 10 <br /> (MAXIMIAI ALLOWABLE TPN LEVELS (PPM)TPH 10,000 1000 100 <br /> FOOTNOTES: —If docuaanted soil and/or grand water contaminstion is present, do not complete the Leaching potential <br /> analysis. (i.e., site is currentty on UGT Contamination List for soil or grand 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 STXSE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> 'JI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are 3TX 3 E or TPN Concentrations > Allowable Levels -Yes No <br /> 2. Recam1end Site Closure Yes y No 'If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENICR <br /> CONCUR 'WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YESI NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED / / <br /> NAMJAE OF � <br /> E` LUATCR <br /> EH 23 30 (UGTWKSHT)\5/90 <br />