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SAN JOAQUIN COIftdY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I, '� WORKSHEET FOR SITE CLOSURE EVALUATION DATE */b 51qg <br /> NAME OF FACILITY ""��p� Lsop SWEEPS CODE <br /> ADDRESS j, /vI/% rn TANK ID k - <br /> TANK SIZE - K k FUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit R - Facility Status Code Doc.Soil/GW Cont Yes No <br /> Nurber of Tanks at facility Age of Tanks(if available) Type of Tank Steel FbrgL SNL Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? 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 I TPH-G TPH-01 Pb/ED8 <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 No Depth to Ground Water a Ret/Year 56. ; Average Annual Pre:ipitationlA= 14 10-25 <br /> On-Site WeLL(S) Yes No Number 8 Type Irr Dam Pub <br /> 5 Score S Score S Score <br /> Distance to Wells) from Tank ft; ft; ft C 10 pis 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 /> Minimus Depth to groundwater frena the Soil Sample (feet) •��' >100 51-100 19125-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None 6i Unknown (Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxxl 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of Leachate (i.e., septic systems, water wells, ponds) Rom Unknown Present <br /> Unique site features: Recharge area, coarse sail, nearby wells. C1 At Least More than <br /> xxxxxx <br /> More 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 /> fl. .u4,/,, Ic d.p. <br /> T=�•�• -""$Of' •;�//ii. 8 T X E B T X E <br /> to-A, MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> SaffiplRes(nit: GASOLINE 1000 100 10 <br /> �I O ! U�+.'T//I" MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH—�1 DIESEL 10,000 1000 100 <br /> FOOTNOTES: "'If docuaented soil and/or ground water contamination is present, do not coaplete the Leaching potential <br /> analysis. (i.e., site is currently an 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 Concentrations > ALLoweble Levels "as No <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 <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES( REFERRED TO SITE MITIGATION FOR EVALUATION YES <br /> DATE REFERRED / / DATE CLOSURE L TTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />