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SAN JOAOUIN C( PUBLIC HEALTH SERVICES/ENVIRONMENTAL NEA' DIVISION <br />LCRKSHEET FOR SITE CLOSURE EVALUATION ` _ DATE <br />(NAME OF FACILITY I .-/J�wYY SWEEPS CODE <br />ADDRESS TANK ID # <br />I / TANK SIZEI i -:Y <br />II. GENERAL SITE HISTORY <br />FUEL TYPEI eelp <br />is permit current? <br />Yes <br />No <br />Permit # <br />- <br />Facility Status Code12::7 <br />No <br />1 Doc.Soil/GW Cont <br />Yes <br />14 <br />No <br />Yes <br />Number of Tanks at facility <br />If yes, what was repaired? <br />Age of Tanks(if available) <br />U e <br />TYpe of Tank <br />Steel <br />Fbrgl <br />Yes <br />Sngl <br />Dual <br />III. TANK HISTORY <br />Was Tank tested? <br />Yes <br />No <br />Failed precision test 7Yes <br />Ref/Year <br />No <br />If <br />yes, give date(s) <br />14 <br />Was a repair made to the tank system? <br />Yes <br />to <br />If yes, what was repaired? <br />o <br />Was repair done under inspection? <br />Yes <br />Irr <br />No HWere soil samples analyzed? <br />Yes <br />No <br />BTXE <br />TPH-G <br />TPH-D <br />Pb/EDB <br />Type of failure/discharge <br />catastrophic <br />long-term leakage <br />overfill <br />unknown <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALT515) <br />Soil Samples Received Yes <br />No <br />Depth to Grosd Water <br />Ref/Year <br />Average Arcual Precipitation <br />A= <br />14 <br />10-25 <br />On -Site WeIL(s) <br />Yes <br />o <br />Number & Typal <br />Irr <br />Dao <br />Pub <br />S <br />C <br />Score <br />10 pts <br />S <br />C <br />Score <br />9 pts <br />S <br />C <br />Score <br />5 pts <br />Distance to WeLL(s) from Tank <br />ft; ft; ft <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />V. Site Feature - Leaching Potential Analysis <br />Minimum Depth to groundwater from the Soil Sample (feet) Z 7 � <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) <br />xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />None <br />Unknown <br />Present <br />of leachate (i.e., septic systems, water wells, ponds) <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />At least <br />More than <br />Xxxxxx <br />None <br />one <br />one <br />+ <br />' C# <br />COLUMN TOTALS»>TOTAL PCINTS <br />Sample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />s <br />40 pts or Less <br />�h\�•.•o6S/q� <br />B <br />T <br />X <br />E <br />B <br />T <br />X <br />E <br />?1= Cir /qty <br />MAXIMUM ALLCWA3LE 8 -T -X -E LEVELS (PPM) <br />1 <br />50 <br />50 <br />50 <br />.3 <br />.3 <br />1. <br />I <br />1. <br />NA\3 <br />Sle Result: <br />7; <br />GASOLINE <br />1000 <br />100 <br />10 <br />1> PD's ��-� <br />MAXIMUM ALLOWABLE TPS LEVELS (PPM) <br />/./.D.- l-Wkl TPH-& <br />DIESEL <br />10,000 <br />1000 <br />100 <br />FOOTNOTES: ""if documented soil and/or grand 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 TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />-D <br />VI. STAFF 2ECOMMENDATION/CONCLUSION � <br />!, L D� <br />1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No ,��,pP <br />I£i S oia AZe <br />2. Recommend Site Closure Yes No �If Yes, Refer " Site Mitigation for Evaluation - $$f�M�� -& <br />V11. <br />Vf1. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/ NIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES <br />DATE REFERRED / / DATE CLOSURE LETTER MAILED / / <br />NAME OF i of J <br />EH 23 80 (UGTWKSHT)\5/90 <br />