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SAN JOAQUIN C f PUBLIC HEALTH SERVICES/ENVIRONMENTAL NEA DIVISION <br /> IMIT WORKSHEET FOR SITE CLOSURE EVALUATION DATE /�— <br /> NAME OF FACILITY ` rl'�HCSWEEPS CODE <br /> i ADDRESS TANK ID S - a <br /> TANK SIZE 5 D FUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> a permit current? Yes No 1/ Permit # - Facility Status Code1:5-3 1 Doc.Soit/GW Cont Yes No <br /> Humber of Tanks at facility Age of Tanks(if available)I (Type of Tank l Steel brgL Sngt Dust <br /> .!'. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 1 Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes Mal If yes, what was repaired? <br /> ,las repair done under i.,ti on? 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 Average Annual Precipitation A- 14 10.25 <br /> On-Site WeLL(S) Yes No Number 8 Type Irr Dao Pub <br /> S Score S Score S Store <br /> Distance to Wetl(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 /> �Mininun Depth to groundwater from the Soil Sample (feet) -30— >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 /> Man-Made conduits which increase vertical migration <br /> �f 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 zz one <br /> COLUMN TOTALS»>TOTAL POINTS I Q + J� + O J 7 <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pis 40 pts or less <br /> B T X E B T X E <br /> MAXIMUM ALLOWABLE 3.T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> N f MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 1 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the Is <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 2ECOMMENDATIOM/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation forEvaluation <br /> VII. REVIEW EVALUATION - TO SE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EN 23 80 (UGTWKSHT)\5/90 <br />