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151211letllu'i <br />TANK SIZE11gb" <br />11. GENERAL SITE HISTORY <br />SAN JOAQUIN CD PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL (VISION <br />,,.— JORKSHEET FOR SITE CLOSURE EVALUATION DATE 3 —/,;)— �7. <br />SWEEPS CODE <br />S TANK ID #1_3 <br />FUEL TYPE D)•c T/L /J%� <br />Is permit <br />current? <br />Yes <br />1xi <br />No <br />Failed precision test T <br />Permit # <br />Ref/Yea <br />-5 <br />Facility Status Code <br />1 <br />6 % <br />Doc.SOil/GW Cont <br />Yes <br />Yes <br />No <br />I xiIf <br />Number of <br />Tanks at <br />facility <br />Yes <br />Irr <br />Age of <br />Tanks(if available) <br />Yes <br />Type of Tank <br />Steel <br />Fbrgl <br />BTXE <br />Sngl <br />Dual <br />S <br />C <br />0 <br />R <br />E <br />III. TANK HISTORY v <br />Was Tank tested? <br />Yes <br />x <br />No <br />Failed precision test T <br />Yes <br />Ref/Yea <br />No <br />I x <br />If yes, give date(s) <br />DATE REFERRED <br />Was a repair made to the tank system? <br />Yes <br />No <br />I xiIf <br />yes, what was repaired? <br />was repair done under inspection? <br />Yes <br />Irr <br />No <br />Were soil samples analyzed? <br />Yes <br />Pub <br />No <br />S <br />C <br />0 <br />R <br />E <br />BTXE <br />S <br />C <br />0 <br />R <br />E <br />TPH-G <br />S <br />C <br />0 <br />R <br />E <br />TPH-0 <br />Distance to Wells) from Tank <br />Pb/EDB <br />Type of failure/discharge <br />Minimum Depth to groundwater from the Soil Sample (feet) 3 17 <br />catastrophic <br />long-term leakage <br />overfill <br />A0 <br />unknown <br />Fractures in subsurface (applies to foothills or mountain areas) <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALTSIS) <br />Soil Samples Received <br />Yes <br />No <br />Depth to Ground water <br />30 <br />Ref/Yea <br />NO <br />Average Annual Precipitation <br />A=114 <br />DATE REFERRED <br />10-25 <br />On -Site Wells) <br />Yes <br />No <br />Number 8 Type <br />Irr <br />Dom <br />Pub <br />S <br />C <br />0 <br />R <br />E <br />Score <br />10 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />9 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />5 pts <br />if <br />condition <br />is met <br />Distance to Wells) from Tank <br />ft; ft; ft <br />V. Site Feature - Leaching Potential Analysis <br />Minimum Depth to groundwater from the Soil Sample (feet) 3 17 <br />>100 <br />51-100 <br />A0 <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />' © <br />None <br />Unknown <br />Present <br />Average Annual Precipitation (inches) <br />xxxxxx <br /><10 <br />9 1 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />Present <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />xxx/xxxx <br />None, <br />At least <br />one <br />More than <br />one <br />COLUMN TOTALS»>TOTAL POINTS <br />(� <br />+ <br />� 7 <br />+ <br />® <br />= 3_J <br />Sample Result: (e T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />41 - 48 pts <br />40 pts or less <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />B <br />1 <br />TX <br />50 <br />50 <br />E <br />50 <br />B <br />.3 <br />T <br />.3 <br />X <br />1. <br />E <br />1. <br />NA\3 <br />Sample Result: <br />_TPH <br />MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br />GASOLINE <br />1000 <br />100 <br />10 <br />DIESEL <br />10,000 <br />1000 <br />100 <br />FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the feat <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 TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX 8 E or TPN Concentrati Allowable Levels *Yes No <br />2. Recommend Site Closure Yes I VIN01 If Yes, Refer to Site Mitigation for Evaluation <br />v1I REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE <br />YES <br />NO <br />REFERRED TO SITE MITIGATION FOR EVALUATION <br />YES <br />NO <br />DATE REFERRED <br />DATE CLOSURE LETTER MAILED <br />NAME OF <br />EVALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />