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SAN JOAQUINY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE DIVISION <br /> I T WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY )r' _ G SWEEPS CODE <br /> ADDRESS TANK ID # <br /> TANK SIZE FUEL TYPE <br /> II. GENERAL SITE HISTORY *** <br /> is permit current? Yes No Permit # - Facility Status Code Doc.Soit/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 I 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/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 Water ?; Ref/Year g6 Average AnnuaL Precipitation A=114 10-25 <br /> On-Site WeLL(s) Yes No Number 8 Type Irr Dam Pub <br /> S Score S Score S Score <br /> Distance to WeIL(s) from Tank ft; ft; ft C 10 pts C 9 pis 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 ` 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None C <br /> 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 q 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 36 I = <br /> Sample Result: IS T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> 'T��A.•oofFw• B T % E 8 T X E <br /> ��hl•d•;.00, ., MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 1 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> /. p'; %pli-c- MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> A,Q.; TPH-•Q 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 8TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION " ,6 S o�J/f7 <br /> '>7 Tac c Oo 1 Q/k <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels 'Yes Na <br /> 2. Recommend Site Closure Yes o *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 71NO REFERRED TO SITE MITIGATION FOR EVALUATION YES I rNO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />