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SAN JOAQUIN r TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEP DIVISION <br /> 1. ST WORKSHEET FOR SITE CLOSURE EVALUATION - DATE <br /> !NAME OF FACILITY SWEEPS CODE <br /> 'ADDRESS (TANK ID # 3 - - / /_ _ /i <br /> TANK SIZE j A 6 o FUEL TYPE c0 (J <br /> 11. GENERAL SITE HISTORY r•( �( <br /> yer <br /> !s permit current? Yes No Permit # Facility 52attffi Lade Ooc.Soil/GW ContYes No <br /> Number of Tanks at facility IAge of Tanks(if available)I (Type of Tank l Steell Fbrgl Sngl Duall <br /> III. TANK HISTORY <br /> Was Tank tested? Yes I 0 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 BTXE TPN-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 /> lSoil Samples Received Yes No Depth to Ground Water Ref/Year Average Annual Precipitation A= 14 .10-25 <br /> :On-Site We(l(s) Yes No Number & Type Irr Dam 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 /> Minimum Depth to groundwater from the Soil Sample (feet) >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) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + = <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> 0 T % E 8 T % E <br /> MAXIMUM ALLOWABLE B-T-%-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: - GASOLINE 1000 100 10 <br /> 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 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> \2 1f 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 TPN Concentrations > Allowable Levels `Yes No <br /> 2. Recommend Site Closure IYes No -1f Yes, Refer to Site Mitigation for EvaLuaticn <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO IREFERRED 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 />