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I SAN JOAQUIN CW 'IBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH <br /> —VISION <br /> U WORKSHEET FOR SITE CLOSURE EVALUATION <br /> NAME OF FACILITY DATE <br /> SCODE <br /> ADDRESS <br /> TANK SIZETANK ID # <br /> FUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? Yes Na Permit # - Facility Status Code Doc.Soil/CW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) <br /> Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 Yes <br /> No If yes, give date(s> / / / / <br /> Was a repair made to the tank system? Yes No It yes, what was repaired? ' <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No <br /> BT%E TPH-C 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 <br /> Ref/Year Average Arcual Precipitation A= 14 10-25 <br /> On-Site WeIL(s) Yes No Number & Type Irr Dom Pub <br /> Distance to Wells) from Tank ft; S Score S Score S Score <br /> ft; ft C 10is <br /> 0 if P C i pts C 5 pts <br /> 0 f 0 if <br /> V. Site feature - Leaching Potential Analysis R condi[i on R condition R caMition <br /> E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) <br /> >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> None Unknown Present <br /> Average Annual Precipitation (inches) <br /> 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) <br /> None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby Wells. <br /> At least More than <br /> xxxxxx None one <br /> one <br /> COLUMN TOTALS>»TOTAL POINTS <br /> Sample Result: (8 T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 4gis <br /> P 40 pts or less <br /> MAXIMUM ALLOWABLE B-T-X-ELEVELS (PPM) 1 50 50 50 ,3 ,3 1.X �- <br /> Sample Result: NA\3 <br /> TPN MAXIMUM ALLOWABLE TPH LEVELS (PPM) GASOLINE 1000 100 10 <br /> DIESEL 10,000 1000 100 <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.)\1 !f 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 /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPN Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TD BE COMPLETED BY A SUPERVISOR/SENIOR <br /> [EVAL <br /> UR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> REFERRED / / DATE CLOSURE LETTER MAILED <br /> OF <br /> UATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />