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SAN JOAOUIN 1TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE DIVISION <br /> I. %uGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY <� � SWEEPS CODE ;�,3 <br /> (ADDRESS /� �� S �( TANK ID # <br /> .;TANK SIZE FUEL TYPE ` <br /> i � <br /> 11. GENERAL SITE HISTORY <br /> �rw <br /> Is permit currNo Permit # - Facility Status Code 0oc.Soi L/GW Cont Yes No <br /> ent? Yes <br /> (Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No If yes, give date(s) ,5/i 9/Aa; 3 <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? dr(J _ _ <br /> Was repair done under inspection?(Yes No Were soil samples analyzed? Yes Na BTXE TPH-G TPH-0 Pb/EDT <br /> of failure/discharge catastrophic long-term Leakage 17 <br /> verfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No IDepth to Ground Water Ref/Year Average Annual Precipitation A= 14 10-25 <br /> On-Site WeLL(s) Yes I No Number 8 Type Irr Dome Pub <br /> S Score S Score 5 Score <br /> Distance to WeLI(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if O if O if <br /> R condition R condition R condition <br /> IV. 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 is foothills or mountain areas) None Unknown Present <br /> Average Annual Precipitation (inches) x xxxx 00 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 + + <br /> 'Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> B T X E B T X E <br /> 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 /> MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: --If documented sail 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. i <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPN Concentrations > Allowable Levels -Yes No <br /> 2. Recommend Site Closure Yesl 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 IREFERRED TO SITE MITIGATION FOR EVALUATION YESI NO <br /> DATE REFERREDI (DATE CLOSURE LETTER NAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />