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SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> �• '1ST WORKSHEET FOR SITE CLOSURE EVALUATION DATE l/ <br /> NAME OF FACILITY T /l�h / /�. - SWEEPS CODE �P <br /> Pi / Tusl 57hJ <br /> ADDRESS �- / ( TANK [D # <br /> TANK S(2E1 ✓ FUEL TYPE �/GP <br /> 11. GENERAL SITE HISTORY <br /> •.e <br /> Is permit current? Yes No Permit # - Facility Status Code ," ; Doc.Sail/GW Cont Yes No , <br /> Nunber of Tanks at facility Age of Tanks(if available) ,�:'� Type of Tank Steel G rgl Sngl Duel <br /> i <br /> 111. TANK HISTORY <br /> iWas Tank tested? Yes No .,,� Failed precision test T Yes No i If yes, give 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 BTXE TPf1-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic tong-term leakage overfill unknow other: <br /> 1V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Sanples Received YesNo Depth to Grovel Water Cr„ ' Ret/Year �h Average Arcual Precipitation A-114 10-25 <br /> On-Site Wells) Yes No l Nutter i Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to Wells) 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 E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Swpte (feet) yD -/S-d3 >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) More ,/ Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) Nora - Unkm present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS I ` + ♦ C— G/� <br /> Saaple Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 s 40 pts or less <br /> T X E B T I X <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 So .3 .3 1. 1. NA\7 <br /> Sad a Result: �GASOLINE 1000 � 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH ESEL 10,000 1000 100 <br /> FOOTNOTES: If documented soil and/or grovel water contamination is present, do not complete the Leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or grovel water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth A-5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXSE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diene L). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 3 E or TPN Concentrations > Allowable Levels *Yes No �- <br /> 2. Recommend Site Closure Yes No elf Yes, Refer to Site Mitigation far Evaluation <br /> VII_ REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECCMMENDATION FOR CLOSURE YES( , NO (REFERRED TO SITE MITIGATION FOR EVALUATION YES NO N— <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR( _ <br /> EH 23 30 (UGTWKSHT)\S/90 <br />