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SAN JOAQUiAM19UNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HF" -H DIVISION <br /> I• GST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY �Li , �+ + .� SWEEPS CODE C, <br /> ADDRESS TANK ID # <br /> TANK SIZE fj 0D ,4 FUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> *** <br /> Is permit current? Yes No Permit # - Facility Status Code 57 Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility , Age of Tanks(if available) V,�. Type of Tank Steel ,/ Fbrgl Sngl 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 71f 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 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 Wrage Annual Precipitation A= 14 10-25 <br /> On-Site Well s) Yes X No Number & Type 1­1Irr Dam I Pub <br /> S Score S Score S Score <br /> Distance 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 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) 2- tNone <br /> 51-100 5 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) Unknown Present <br /> Average Annual Precipitation (inches) 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) Unknown S Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. �p At least More than <br /> I one one <br /> COLUMN TOTALS>>>TOTAL POINTS ' 2 7 * <br /> Sample Result- (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 0 pts or less <br /> 7=- 4•6'i'SSA°% B TX E B T X E- <br /> XZA-O...""``-7�''• MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> .Q „!7 TpH-G 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 LOT 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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). / <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISO /SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES IV <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/ 0 <br />