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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I• ST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY p� SWEEPS CODE <br /> ADORESS Z3 V TANK ID 0 <br /> TANK SIZE �7 FUEL TYPE 4. I <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit 9 - Facility Status Code -f -j Doe.Soi l/GY Cont Yes N <br /> Number of Tanks at facility Age of Tanks(if available) ��,.4.� Type of Tank Steel Fbrgl Sngl Dual <br /> Ill. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 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 inspections Yes No Were soil samples analyzed? Yes No BTXE F 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/Year Average AmuaL Precipitation A- 14 10.25 <br /> On-Site Wells) Yes No Number & Type Irr Dam Pub <br /> S Score S Score S Score <br /> Distance to Wells) from Tank ft; ft; ft C 10 pis C 9 pis 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 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 410 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 1 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 L + 7 <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 48 40 pts or Less <br /> A11 a T X E 8 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 l 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPN DIESEL 10,000 1000 100 <br /> FOOTNOTES: If documented soil and/or ground water contamination is present, do ate 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 c5 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 TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VL STAFF RECOMMENDATION/CONCLUSION (p 4,a( = 9 tom Pas sc s <br /> 7Vvra-i-GYGriLn+ u*7 J+- , <br /> 1. Are BTX & E or TPN Concentrations > Allowable Levels `Yes NoIX <br /> 2. Recommend Site Closure Yes No FIf Yes, Refer to Site Mitigation for Eva Luation b-11)-q j /_T43 <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE NITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />