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SAN JOAQUIN INTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL I JH DIVISION <br /> I, GST WORKSHEET FOR SITE CLOSURE EVALDATE <br /> NAME OF FACILITY SWEEPS CODE .3 / <br /> ADDRESS 7 Q c �� TANK ID # <br /> TANK SIZE I FUEL TYPE QQ S© <br /> 11. GENERAL SITE HIS14RY C/ <br /> Is permit current? Yes INOX Permit # - Facility Status Code Doc.Soil/GW Cont Yes No <br /> Nuriber of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> 111. 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 =If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPN-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 x <br /> No Depth to Ground Water 30 Ref/Year Average Annual Precipitation A= 14 10-25 <br /> On-Site Well(s) Yes No Number & Type Irr Dan Pub <br /> S Score S Score S Score <br /> Distance to Wells) from Tank ft; 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)— >100 51-100 O 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 Resu t: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> E'P b :' 7. � <br /> T 43 <br /> MAXIMUM ALLOWABLE B-T-%-E LEVELS (PPM) B 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result• — GASOLINE 1000 100 10 <br /> p O--G=�J D MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH I DIESEL 10,000 1000 100 <br /> FOOTNOTES: *•*If documented soil and/or ground water contamination is present, do not complete the teaching 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, score0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION -s <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels W �—es No LZ'1C�� /t[.Q _ol <br /> 2. Recortmend Site Closure Yes No *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 INA <br /> 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 />