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SAN JOAQUIN ( 'Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL NEP DIVISION <br /> I. •MT WORKSHEET FOR SITE CLOSURE EVALUATION +^� DATE <br /> NAME OF FACILITY D SWEEPS CODE <br /> ADDRESS q TANK ID # <br /> TANK SIZE �`�� FUEL TYPE Q 4 <br /> I1. GENERAL SITE HISTORY <br /> Is permit current? Yes No I xPermit # - Facility Status Code f Dac.Soi L/GW Cant Yes No <br /> Number of Tanks at facility Age of Tanks(if avajLabLe)j&jk Type of Tank Steel Fbrgl Sngl Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? Yes No I A <br /> 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 inspection? Yes Na Were sail samples anatyzedV 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 Mol Depth to Ground Water `f0 Ref/Year g(p ; Average Annual Precipitation A-114 10-25 <br /> On-Site Welt(s) Yes No Number 8 Type Irr Dan Pub <br /> S Score S Score S Score <br /> Distance to Wells) from Tank it; ft; ft C 10 pts 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 Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the SOIL Sample (feet) 4D—15�a >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 <10 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) Name Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby welts. At least More than <br /> xxxxxx None one <br /> COLUMN TOTALS>»TOTAL POINTS 10 + 1 - <br /> Sample Result(: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 1 - 48 its 40 pts or less <br /> T % E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. MA\3 <br /> SampleResult: GASOLINE 1000 100 10 <br /> AN IN) MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do 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 c LG(/� <br /> 1. Are BT% 8 E or TPH Concentrations > Allowable Levels *Yes No O7�Kv 4oa�/,' <br /> 2. Recommend Site Closure Yes No 'If Yes, Refer to Site Mitigation for Evaluation �"^C a * ' �(�1�' <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 YESI NO 1 601 <br /> DATE REFERRED IDATE CLOSURE LETTER MAILED <br /> XAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />