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SAN JOAQUIN•...Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL A DIVISION <br /> I UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE �.Q <br /> NAME OF FACILITY SWEEPS CODE <br /> 3n � ` 1 . TANK ID # <br /> ADDRESS —I V <br /> !TANK SIZE 5-(DorjFUEL TYPE /'t V S <br /> (I. GENERAL SITE HISTORY �ff <br /> its permit current? Yes No Permit # Facility Status Code Doc.Soil/GW Cont 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 No Failed precision test ? Yes No If yes, give date(s) <br /> jWas a repair made to the tank system? Yes No If yes, what was repaired? <br /> �.Was repair done under inspection? Yes Na Were soil samples analyzed? Yes No BTXE TPH-G TPH•D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill L <br /> unknown other: <br /> !V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ;Sail Samples Received Yes No Depth to Ground Water Ref/Year 3 Average Annual Precipitation A= 14 10-25 <br /> ,On-Site Wells) Yes No Number 8 Type Irr • Dam Pub <br /> S Score S Score S Score <br /> ;Distance to Wells) from Tank ft; ft; 20 ft C 10 pts C 9 pts C 5 pis <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 met <br /> .Minimum Depth to groundwater from the Soil Sample (feet) <br /> 5 <br /> >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 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration Nene Unknown Present <br /> �lof leachate (i.e., septic systems, water wells, ponds) <br /> jUnique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one I� one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> (Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> .8 '+'t PPS 613",%3 PPO B T X E B T % f E <br /> -K to q3 FPO <br /> .2 lqz ppi ' MTBE$ MAXIMUM ALLOWABLE B-T-%-E LEVELS (PPM) 1 50 50 50 .3 .3 1.� 1. NA\3 <br /> 'Sample Result: <br /> GASOLINE 1000 100 10 <br /> I� J MAXIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL 10,000 1000 100 <br /> TPH <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 LOT 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 RECOMMENOATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allo ble Levels 'Yes No <br /> 2. Recommend Site Closure Yes No if Yes, Refer to Site Mitigation for Evaluation <br /> VIE. 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 / / DATE CLOSURE-LETTER <br /> NAME OF / <br /> EVALUATOR I(<<C <br /> EH 23 80 (UGTWKSHT)\5/90 <br />