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SAN JOAQUIN NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HI i DIVISION 7 <br /> 1• -'QST WORKSHEET FOR SITE CLOSURE EVALUATION — ATE <br /> AME OF FACILITY ECORD ID <br /> ADDRESSi ANK ID # <br /> TANK SIZE iFUEL TYPE <br /> I1. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # - acility Status Code oc.Soil/GW Cant es o <br /> 11 umber of Tanks at facility ge of Tank(if available) ype of Tank teel Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired7 <br /> Jas repair done under inspection? es o ere soil samples analyzed? es a TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-tern Leakage verfill nkncwn I lother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water I ITef/Year verage Annual Precipitation = 4 0-25 <br /> n-Site Well(s) es o I r 8 Type Irr I am I ub <br /> S Score S Score S Score <br /> istance to WeLL(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ordition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50L <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> Average Annual Precipitation (inches) xxxx <10 9 10-25 KMXxxx 26-402 <br /> Ian-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, or wells. At least 4ore than <br /> [Muncipal=>2000 ft; domestic=>500 it; irr/agricultural=present] xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS I. 3 . I <br /> Sample Result: (8 T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B T X E 8 T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> Sample(!YuLt: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> ZZAA <br /> TPH(P) IESEL 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 /> \22 If precipitation is > 40 inches, score 0 points. <br /> \33 Levels for BTXBE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes IN. <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES INO <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />