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i <br /> SAN JOAQUIN v PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE . -0IVISION M <br /> I. WORKSHEET FOR SITE CLOSURE EVALUATION 7 <br /> NAME OF FACILITY ra �L' ` �, J l SWEEPS CODE 3` 6 <br /> f c ij TANK ID # Q <br /> ADDRESS <br /> TANK SIZE FUEL TYPE <br /> Ii. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit - Facility Status Cade Doc.Soit/GW Cant Yes No <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 Na 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 underinspection? Yes No Were sail samples analyzed? Yes No BTXE TPH-G TPH-0 Pb/EDB <br /> Type of failure/discharge , catastrophic Lang-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 Ref/Year Average Annual Precipitation A= 14 .14-25 <br /> On-Site WeLL(s) Yes Na Number & Type Irr Dam Pub <br /> S Score S Scare S Scare <br /> Distance to WeLI(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 4 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 Soit Sade (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 ii<10 4 10-25 xxxxxxx 25-40\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 sail, nearby weLLs. a At Least More than <br /> xxxxxx None one one <br /> P ' COLUMN TOTALS»>TOTAL POINTS <br /> S vmLe Res-ilt: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> 'S j <br /> . <br /> 1r�! B T X E B X E MAXIMUM ALLOWABLE B-T-X-f LEVELS (PPM) 1 50 i50 50 .3 I.T <br /> 3 1. 1. NA\3 <br /> y, GASOLINE 1000 100 10 <br /> I L-' qsuLt <br /> 31 G`)� i � MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> S - o�15p k TPH` a DIESEL ]0,000 1000 tOD <br /> FOOTNOTES. ***If documented soil and/or ground water contamination is present, do not complete the Leaching potential <br /> S3/ DU analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> S. 7 a 170 \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depthj< 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 /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are STX & E or TPH Concentrations > ALlowabte Levels *Yes No <br /> Z. 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 /> a <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF I. <br /> EVALUATOR !1 <br /> EN Z3 80 (UGTWKSHT)\5/90 <br /> i; l <br />