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SAN JOAQUIN * PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE (VISION <br /> 1. T WORKSHEET FOR SITE CLOSURE EVALUATION �01.� �( DATE ?z O <br /> NAME OF FACILITYC C, - „\ SWEEPS CODE <br /> ADDRESS / 0,7 N G - TANK ID # - - <br /> TANK SIZE FUEL TYPE l�M r <br /> II. GENERAL SITE HISTORY . <br /> *** <br /> Is permit current? Yes N Permit # Facility Status Code Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility / Age of Tanks(if available) 7 Type of Tenk Leel Fbrgl Sngt Dual V <br /> 111. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? 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 analyzed? Yes No BTX TPHTPH-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 No Depth to Ground Water 10 Ref/Year (q8 6 11verage Annual Precipitation A= 14 10-25 <br /> On-Site Well(s) Yes No Number & Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to Wells) 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 S 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown S 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) None Unknown S Present <br /> Unique site features: Recharge area, coarse soil, nearby welts. At Least More than <br /> xxxxxx None one � one <br /> COLUMN TOTALS>»TOTAL POINTS ZD - Zp <br /> Sample Result: (e T X 0(t RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> //J B T X I E B T X E <br /> AMO MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result- GASOLINE 1000 100 10 <br /> �d fe N MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> .FP+h— 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 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 RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > At towable Levels *Yes No <br /> 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Eva Luation <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 YES NO <br /> DATE REFERRED r / C / 4, DATE LOSURE LETTER MAILED <br /> v <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />