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SAN JOAQUIN COIJM :BLIC HEALTH SERVICES/ENVIRONMENTAL HEAL* .SION <br /> 11fflW.10RKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY SWEEPS CODE <br /> EADDREISTANK ID #f j)00 FUEL TYPEI ? <br /> 1. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit # - Facility Status Code L/,�' Doc.SoiL/GW Cont Yes No X <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrg! Sngl Dual <br /> II. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No� If yes, give date(S7) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? w ti'- I:.aLZf1 f a <br /> ze <br /> Was repair done under inspection? Yes X <br /> No H <br /> Were soil saaples analyzed? Yes No BTXE TPH-G TPH-0 I Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakageoverfill' unknown other: <br /> V. 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 & Type Irr Dom Pub <br /> S Score S Scare S Scare <br /> Distance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pis <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) l 4 — >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 /> of leachate (i.e., septic systems, water wells, ponds) f ' None 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: (8 T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40-pts or Less <br /> rl.s�4 <br /> B T X E B TX E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> _[ I <br /> Sample Result: GASOLINE 1000 100 10 <br /> } ', �,•.t 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 leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> \1 1f depth is > 5 ft. and < 25 ft., score 0 paints. If depth <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, scare 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> 1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation <br /> IT. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES 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 />