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SAN JOAQUIN ' +TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE DIVISION <br /> 1. ST WORKSHEET FOR SITE CLOSURE EVALUATION .1- DATE 'GS/� 7 <br /> NAME OF FACILITY /6k V SWEEPS CODEJ Z ?� <br /> ADDRESS ysd - C./L&D ug_ TANK ID # 3 <br /> TANK SIZE Z 'IC S� FUEL TYPE ArE$EL <br /> v/ <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? Yes Na Permit # - Facility Status Code Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel fbrgl SngL Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed 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 /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes Na BTXE TPH-G TPH-0 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 FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water Ref/Year 9-& ; Average Annual Precipitation A= 14 10-25 <br /> On-Site WeM s) Yes No Number 8 Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to WeLL(s) frac Tank ft; ft; ft C 10 pts C 9 pts C 5 pis <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 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 10-25 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 None ? one /one <br /> COLUMN TOTALS»>TOTAL POINTS 3 L <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> 8• 0�� E- z Z� <br /> B T X E B T % E <br /> arg^ZS40 MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> / MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> if TPH DIESEL 10,000 1000 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 BT%8E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION � 'TJ V A I T <br /> 1. Are BTX 8 E or TPH Concentrations > A[LowabLe Levels *YesNo <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/S IOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES I ViNO <br /> DATE REFERRED DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />