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SAN JOAOUIN TY PUBLIC HEALTH SERVICES/ENVIRONMENTALH DIVISION <br /> 1• `6S ST WORKSHEET FOR SITE CLOSURE EVALUATION DATE �— <br /> 1-5-64 <br /> NAME OF FACILITY - SWEEPS CODE <br /> ADDRESS 7 , TANK ID # <br /> TANK SIZE ice' FUEL TYPE <br /> 11. GENERAL SITE HI RY X-•-JOC.. <br /> J �e* <br /> [11s,permil current? Yes No Permit # - facility Status Code Doc.Soil/GW Cont Yeer of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl SngL Dual <br /> 111. TANK HISTORY <br /> Was Tank test ed? 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 inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakageoverfill 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 j11 Ref/Year I W,4', Average Annual Precipitation A= 14 10-25 <br /> On-Site WeLL(s) Yes No Number 8 Type Irr Dom Pub <br /> 5 Score S Score 5 Score <br /> Distance to Wells) from Tank it; ft; ft C 10 pts C 9 pts C 5 pts <br /> O 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)3o- >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) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> m COLUMN TOTALS>>>TOTAL POINTS + + - <br /> Sample Resul : (8 T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> T = 171 LDt3= aoo <br /> x - 1100 8 T X E 8 T % E <br /> / MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. i- NA\3 <br /> Sample Result: GASOLINE 7000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TP X(T DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If 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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION O_ !I ,„9_ ^ , <br /> A 11 <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels 'Yes No `-�,hre <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR � � 1 <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES - NO <br /> DATE REfERRED / / (� t DATE CLOSURE LETTER MAILED / / <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />