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,r <br /> SAN JOAQUIN C+k PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE-00..41)IVI SION <br /> OUST WORKSHEET FOR SITE CLOSURE EVALUATION DATE CfI-ZJ9 p <br /> c OF FACILITY U WAVE-(- PCAzA SWEEPS CODE <br /> nDDRESS ��� LLe.ei w "" .�n�.sf� TANK ID # <br /> Fl/TF�'n' nY ,r nl'_ 3tiG-051Sgz"tp <br /> TANK SIZE FUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> •** <br /> Is permit Current? Yes No ✓ Permit # - Facility Status Code DOc.S011/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel X Fbrgl Sngt Dual <br /> 111. TANK HISTORY - <br /> Was Tank tested? Yes No Failed precision test ? YesMoverfitl <br /> s, give dates) <br /> Was a repair made to the tank system? Yes No If yes <br /> Was repair done under inspection? Yes No Were soil s No BTXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leaknknown other: <br /> :V. 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 Annual Precipitation A= 14 10-25 <br /> On-Site Wells) Yes No Number & Type Irr Dom Pub <br /> S Score S Tconditln <br /> Score <br /> Distance to Wells) from Tank ft; ft; ft C 10 pts C 5 pts <br /> 0 if 0 if <br /> R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met <br /> Minimm Depth to groundwater from the Soil Sample (feet) >100 51-100 Ethan <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown P <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic system, water wells, ponds) None Unknown P <br /> unique site features: Recharge area, coarse soil, nearby wells. At least M <br /> xxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + + - <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B 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 /> TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***)f 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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> 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 <br /> I. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR,tWITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />