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SAN JOAQUIN 0 Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA DIVISION <br /> I. rGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY. y"� ' ' ;!� / SWEEPS CODE <br /> ADDRESS TANK 10 fi <br /> TANK SIZE FUEL TYPE SlvCl�p� /,ri <br /> 11. GENERAL SITE HISTORY <br /> is permit current? Yes No Permit # - Facility Status Code DCC.SOil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dust <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test t Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes Na If yes, what was repaired? <br /> Was repair done underinspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPH-D Pb/EDB <br /> 'ype of failure/discharge catastrophic lag-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 WeIL(s) Yes No Number 8 Type Irr Dan Pub <br /> S Score S Score S Score <br /> Distance to Welts) 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) >100 51-100 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 /> lMan-Made conduits which increase vertical migration <br /> of Leachate (i.e., septic systems, water wits, ponds) More Unknown Present <br /> (Unique site features: Recharge area, coarse sail, nearby wells. At least More than <br /> xxxxxx None 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 /> 4 11 N, 0, 8 T X E B T X <br /> MAXIMUM ALLCWABLE B.T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> �l? MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> I TPH DIESEL 10,000 1000 100 <br /> 'FOOTNOTES: ***If documented soil and(or ground water contamination is present, do not camptete the lea tential <br /> analysis. (i.e., site is currently on UGT Contamination List for soft 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. STAF° EECOMMENDATION/CONCLUSION ^-1 _ a „n�L=, n�.t(PP yYV <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable levels *Yes No Lo acL u-1 +eSt- = 4,1 <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 �A SSE S lnv � <br /> CONGER WITH STAFF RECOMMENDATION FOR CLOSUREYES 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)\ /90 <br />