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A <br /> SAN JOAOUIN 01 PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE*DIVISION <br /> 1• T WORKSHEET FOR SITE CLOSURE EVALUATION DATE ` <br /> NAME OF FACILITY SWEEPS CODE - <br /> ADDRESS S1P - TANK ID aY 5 <br /> TANK SIZE ` FUEL 4YPE <br /> 11. GENERAL SITE HISTORYes <br /> JJ e** <br /> Is permit current? Yes No Permit ak - Facility Status Code Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) 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 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/EDS <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 Ref/Year average Annual Precipitation A= 14 10-25 <br /> On-Site Wells) Yes No Number & Type Irr Dom - Pub i <br /> S Score S Score 5 Score <br /> Distance to WeLL(s) from Tank ft; _f t; _f t 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 Jr 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 /> COLUMN TOTALS»>TOTAL POINTS + 3l0 + s = 4I <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> V�J B T X E B T X E <br /> 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 /> G I MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> l TPH 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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No I vl• [ <br /> ��y -- STL4.- t .l rvN �L <br /> l 2. Recommend Site Closure IYesl ' l of F*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 7NO1 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 />