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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> 1- 'GST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY /ln M v ( `y SWEEPS CCOEI <br /> ADORESSI / / S! l (TANK ID #I _ �O <br /> TANK SIZE DOD FUEL TYPE �jfsa <br /> 11. GENERAL SITE HISTORY <br /> m <br /> Is permit current YY as No Permit #I Facility Status Code DoC.SOi I/GW Cont Yes No <br /> Nvnber of Tanks at facility Age of Tanks(if available) cj'7 ype of Tank Steel Fbrgl Sngl Duel <br /> 11I. TANK HISTORY <br /> !Was Tank tested? Yes No Failed precision test ? Yesl If yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what s repaired? , <br /> i <br /> Ives repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-GI TPH-DI IPb/EDB <br /> (Type of failure/discharge Icatastrophic long-term leakage overfill ur*Mwn other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes Nol Depth to Ground Water Ref/Year Average Arcual Precip itationl A= 14 10-25 <br /> On-Site Welt(s)I Yes No (Number & Type Irr Dom 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 0 if <br /> R condition R condition R condition <br /> V. Site Feature • Leaching Potential Analysis E is met E is met E is mei <br /> Minis Depth to groundwater from the Soil Sample (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 <10 9 70-25 xxxxxxx 26-40\2 <br /> 'Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systema:, water wells, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> zxxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + <br /> 'Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 - 48 pts 40 pts or less <br /> a T % 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 /> ISampte Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> OCTNOTES: --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 < Z5 ft., score 0 points. If depth 4--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 BTX & E or TPH Concentrations > Allowable Levels "Yes No <br /> 2. Recommend Site Closure Yesl 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 YES INO <br /> DATE REFERREDi / / IDATE CLOSURE LETTER MAILED / / <br /> (NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />