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SAN JOAOUIN CWNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEti,/ DIV15[ON DATE <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> I. <br /> SWEEPS CODE <br /> NAME OF FACILIT <br /> TANK ID # a U <br /> ADDRESS <br /> TANK SIZE FUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit currents Yes No Permit # " <br /> Facility Status Code Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility <br /> 3 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 7 Yes No if yes, give date(s) <br /> Was a repair made to the tank system? Yes No VjIf yes, what was repaired? <br /> Was repair done under inspections as <br /> No Were soil samples analyzedTPH-D Pb/E08 <br /> ? Yes No BTXE TPH-G <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 POTEN IAL ANALYSIS)itation A= 14 10-25 <br /> Ann <br /> Soil Samples Received Yes No Depth to Ground Water Ref/Year <br /> AverageOn-Site Well !rr Dom Pub s) Yes No Number 8 Type S Score c Score S Score <br /> 9 pts C 5 pts <br /> ft; <br /> ft; ft C 10 pts if 0 if O if <br /> D <br /> Distance to Wells) from Tank R condition R condition R condition <br /> E is met E is met E is met <br /> v. Site Feature - Leaching Potential Analysis >100 51-100 25-50\1 <br /> Minimum Depth to groundwater from the Soil Sample (feet) None Unknown Present <br /> Fractures in subsurface (applies to foothills or mountain areas) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Average Annual Precipitation (inches) <br /> Man-made conduits which increase veuaterlwellseCponds) <br /> None Unknown Present <br /> of leachate (i.e., septic systems, /p At least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None <br /> one one <br /> COLUMN TOTALS»>TOTAL POINTS + + 40 pts or less <br /> RANGE OF TOTAL POINTS 49 pts or more <br /> 41 - 48 pts <br /> Sampte Result: (B T X OR E) 8 T X E B T X E <br /> A NA\3 <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. <br /> 10 <br /> GASOLINE 1000 <br /> 100 <br /> Sample Result: 1000 100 <br /> 1 MAXiMUN ALLOWABLE TPH LEVELS (PPM) DIESEL 10,000 <br /> _TPH p otentiaL <br /> FOOTNOTES: "*if documented soil and/or ground water contamination UGaiion is resent do not c late the leaching p <br /> p <=5 ft., do nonuse table. <br /> analysis• (i.e., site is currently on UG7 Contamination List for soil or ground water. <br /> \1 if depth is > 5 ft. and < 25 ft. score 0 points. If depth (gasoline) or 100 ppm (diesel). <br /> \2 If precipitation is > 40 inc`ecableoat a TPNnconcentration of 10 (9 <br /> \3 Levels for BTXBE are not app <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX b E or TPH Concentrations Allowable Levels *Yes i No <br /> 2. Recommend Site Closure Yes No <br /> �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 F0� EVALUATION 7E5 NO <br /> / DATE CLOSURE LETTER NAILED / <br /> DATE REFERRED / <br /> NAME OF <br /> EVALUATOR <br /> — i nn rur.TuKSHT)\5/90 <br />