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i <br /> SAN JOA0UIN ''- Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL Hf []IVISION <br /> 1. ,T WORKSHEET FOR SITE CLOSURE EVALUATION <br /> ot <br /> NAME OF FACILITY ( � Ct' Sc�f� SWEEPS CODE <br /> ADDRESS ( v7r A TANK ID #-7 11J' - <br /> I. TANK SIZE 'U FUEL TYPE ! <br /> IIS GENERAL SITE HISTORY <br /> www <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 Tank feel Fbrgl Sngl Dual 1� <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 NoLl BTX&rl <br /> TPH-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 /> Soil Samples Received No Depth to Ground Water 10 Ref/Tear lefs Average Annual Precipitation A= i4 10 25 <br /> On-Site WeIL(s) Yes No Number & Type Irr Dam • 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 O 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) >140 .51-100 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 5 Present <br /> Unique site features: Recharge area, coarse soil,.nearby wells. At least More than <br /> xxxxxx None one j one <br /> COLUMN TOTALS>>>TOTAL POINTS + + ZD = ad <br /> Sample Result: (B T X 0 RANGE OF TOTAL POINTS 49 pts or more 41 48 pts 40 pts or less <br /> U B T X E B JT X E <br /> ( mo MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. N1113 <br /> Sample Result: GASOLINE 1000 100 10 <br /> �d TE N MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 4441-- 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 /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > ALI.50abte Levels *Yes 11NO <br /> 2. Recommend Site Closure Yes 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 REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / C / F;" DATE LOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR r <br /> EH 23 80 (UGTWKSHT)\5/90 <br />