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SAN JOAQUIN C Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA DIVISION Q- <br /> 1. 'tftT 6=SHEET FOR SITE CLOSURE EVALUATION DATE UJ/ <br /> NAME OF FACILITY SWEEPS CODE 5— <br /> p 4eg <br /> ADDRESS V• {' ✓ TANK ID S - � <br /> J <br /> TANK SIZE FUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> •ss <br /> Is permit current? Yes No Permit # - Facility Status Code Doc.Soil/GW Cont YesNo <br /> Number of Tanks at facility Age of Tanks(if available)t53 I Type of Tank Steel Fbrgl Sngl Dual <br /> Ill. TANK HISTORY <br /> Was Tank tested? Yes No XFailed precision test ? Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes Vol If yes, what was repaired? <br /> Was repair done order irupectionT Yes No Were soil samples analyzed? Yes No STXE 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 Grind Water Ret/Year Average Arcual Precipitation A= 14 10-25 <br /> IOn-Site Wells) Yes No Number & Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to WeLL(s) from Tank ft; ft; ft C 10 pis 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 /> Minin Depth to groundwater from the Soil Sample (feet) 30- 7=d63 >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) O None Unknown Present <br /> (Average Annual Precipitation (inches) xxzxxx <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 ane <br /> COLUMN TOTALS>»TOTAL POINTS 1 D a • ,3 7 <br /> 'Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 or less <br /> WD BT X E 8 T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. RA\3 <br /> i <br /> Sample Result: GASOLINE 1000 100 10 <br /> N p MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the Lee- r ential <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 /> VI. STAFF 1ECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels 'Yes No <br /> 2. Recommend Site Closure Yes Mo �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 CLOSUREIYES 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)\5/90 <br />