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1 a <br /> SAN JOAOUIN C UaW T WORKSHEETLTH FOR SITE CLOSURERONMENTL EVALUATIONHEALTI�/1 SIGN DATE <br /> I. <br /> SWEEPS CODE <br /> NAME OF FACILITY S pfjOS'/ <br /> TANK ID # - <br /> ADDRESS <br /> TANK SIZE FUEL TYPE <br /> 11. GENERAL SITE HISTORY " <br /> Is permit current? Yes No Permit # - FacYes No <br /> ility Status Code Doc.Soi l/GW Cont <br /> Number of Tanks at facility <br /> 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 dot e(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 BT%E PH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term Leakage overfill unknown ocher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples <br /> Ref/Year Received Yes No Depth to Ground Water c/f �fj Average Annual Precipitation; <br /> A= 14 10-25 <br /> On-Site WeLL(s) Yes No Number 8 Type Irr Dan Pub S Score S Score S Score <br /> Distance to WeIL(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5fpts <br /> 0 if 0 it <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) <br /> >100 51-10025-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> one 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 None Unknown Present <br /> of leachate (i.e., septic systems, water wells, ponds) <br /> At least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> 3G Cj <br /> Samplee,IesuLt: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> -.c2 <br /> B T X E B T % E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 -3 1. 1. RA\3 <br /> GASOLINE 1000 100 10 <br /> Sample Result: <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) 100 <br /> 3 p TPH_ DIESEL 10,000 1000 <br /> FOOTNOTES: <br /> *•"'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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel))). <br /> VI. STAFF RECOMMENDATION/CONCLUSION /'# 5��" <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels -Yes No prPE=(,Ld•).Ole <br /> 'If Yes, Refer to Site Mitigation for Evaluation �'>•j =l l,G i.e� wA.. <br /> 2. Recommend Site Closure Yes No <br /> VII- REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/S NIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />