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SAN JOAQUIN I 'Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEI DIVISION <br /> I, Y'o*riT WORKSHEET FOR SITE CLOSURE EVALUATION -%sO DATE <br /> NAME OF FACILITYSWEEPS CODE _71 <br /> ADDRESS a'—v _ S'hL TANK ID # 3 <br /> TANK SIZE ti �I D� FUEL TYPE W,4s <br /> II. GENERAL SITE HISTYRY <br /> Is permit current? Yes No Pemmmit # - Facility Status Cade Dw.BOiL/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel XFbrgt I 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 No BTXE TPH-G TPH-D 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 4 Ref/Year �� ; Average Annual Precipitation A= 14 10-25 <br /> On-Site WeLL(s) Yea No Number & Type Irr Dam Pub <br /> S Score S Score 5 Score <br /> Distance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if O 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 Semple (feet) ''0-7=3=_3 I >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) 01 None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xsxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of Leachate (i.e., septic systems, water wells, pads) Nene Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> XXXXXXX None ox one <br /> COLUMN TOTALS»>TOTAL POINTS / ✓ * * _ 3 <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more081] <br /> 48 pts 40 pts or less <br /> /411 ND I B T X E X E <br /> ND FC— MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 0 10 <br /> n i ( n, DMAXIMUM ALLOWABLE TPN LEVELS (PPM)l7 /VJ TPH DSESEL 10,000 0 100 <br /> FOOTNOTES: *"If documented soil and/or ground water contamination is present, do not complete the Leaching potential <br /> ane lysis. (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 BTXE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels -Yes No <br /> 2. Recommend Site Closure Yes No if Yes, Refer to Site Mitigation for Evaluation@JCdY <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR + X ' <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION i YESI No <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED / / <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />