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SAN JOAQUIN C- 'TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE' DIVISION <br /> 1. ;T WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY /n/ - ISWEEPS CODE <br /> ADDRESS �- �' �,�,C � TANK ID # $� <br /> TANK SIZE O FUEL TYPE <br /> ll. GENERAL SITE HISTORY <br /> fff <br /> Is permit current? Yes No Permit # - Facility Status Code '�3 Doc.soil/GW Cont Yes No <br /> Number of Tanks at facility —3 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 7 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 am lyzed7 Yes No BTXE TPH-GI 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 at Precipitation A= 14 10-25 <br /> On-Site WCLL(S) Yes No Number 8 Type Irr Dan Pub <br /> S Score S Scare 5 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) 30 >100 51-100 O 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) 10, 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 welts, ponds) None q Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> Xxxxxx None one we <br /> COLUMN TOTALS»>TOTAL POINTS I D1 1 -;�7 1- 37 <br /> Sample Result: (8 T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> ND B T I X I E 8 T X E <br /> MAXIML04 ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Soap le Result: GASOLINE 1000 100 10 <br /> D MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 1011 <br /> FOOTNOTES: *—If documented soil and/or ground water contamination is present, do not complete the Leaching <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 8TX8E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPN Concentrations > Allowable Levels -Yes No <br /> 2. Recommend Site Closure l Yes No .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 NO REFERRED TO SITE MITIGATION FOR EVALUATION YESI NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> E`/ALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />