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SAN JOAQUIN TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE. DIVISION <br /> (. 116ST WORKSHEET FOR SITE CLOSURE EVALUATION _ E:\:\ <br /> -)-" <br /> NAME OF FACILITY -r\ SWEEPS CODE <br /> ADDRESS -al C', !E\, t_—KU CA TANK ID # <br /> TANK SIZE \� FUEL TYPE O <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit # - Facility Status Code Dac.Soil/GW C t Yes No <br /> Number of Tanks at faciLity , Age of Tanks(if avai Lable) \q� Type of Tank Steel Fbrgl Sngl _311 I <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 Ref/Tear Average Annual Precipitation A+4 10-25 <br /> On-Site Wells) Yes No Number 8 Type Irr Dam Pub <br /> S Score 5 Score S !Score <br /> ;Distance to Nell(s) from Tank ft; ft; ft C 10 pis 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 Potentia( Analysis E is met E is met E is met <br /> !Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 (j 125-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None (k Unknown Present <br /> 'Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxzx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None a Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. tj At Least More than <br /> xxxxxx None one c one <br /> COLUMN TOTALS»>TOTAL POINTS * 3W ` <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 49 pts 40 pts or Less <br /> B T X E 6 T X E <br /> 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 /> alkao TPH DIESEL 1 10,000 000 100 <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 BTXBE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels *Yes No <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/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED `� / / •� DATE CLOSURE ETTER MAILED / / <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />