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t SAN joAOUIN ",PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL-:--'IVIStam DATE <br /> WORKSHEET FOR SITE CLOSURE EVALUATION <br /> NAME OF FACILITY SWEEPS CODE /3� <br /> v✓Uh TANK ID # } } S [c c�... <br /> ADDRESS . <br /> k TANK S i ZE yr C7 FUEL <br /> II. GENERAL SITE HISTORY *** <br /> cPermit !« - Facility Status Code S Doc.Soi!/GW Cont Yes No <br /> Is permit urrent? Yes Na <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual ; <br /> I <br /> Iii. TANK HISTORY qLn. <br /> I <br /> Was Tank tested? Yes o Failed"precision test T Yes Na If yes, give date(S) J'/ Y *2;— <br /> Was a repair made to the tank system? Yes No yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPH-D Pb/f D6 <br /> Type of failure/discharge catastrophic long-term Leakage overfILIJ 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 7 oi Ref/Year (� Average Annual Precipitation A-114 10-25 <br /> f On-site W L(s) Yes No Number & Type Irr Dom Pub 5 Score S Score S Score <br /> Distance to Well(s) from Tank ft; ft; ft C if pts C 0 i pts C 5 pts <br /> 0 f if Q iif <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) >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to 4 --` None Unknown Present <br /> Average Annual Precipitation (inches J,xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vel <br /> G17of leachate (i.e., septic systems, i1N� f Hone Unknown Present <br /> Unique site features: Recharge a1 At least More than <br /> xxxxxx None one one <br /> a <br /> COLUMN TOTALS»>iu�,.. . + 3� Y// <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 40 pts or less <br /> B T X 8 T X E " <br /> Z O MAXIMUM ALLOWABLE B-T-X-E LEVELS (FPM) 1 50 50 O .3 .3 1. 1. NA\3 <br /> Sample Result: <br /> GA50LINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH DIESEL 10,00 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, not comple the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination Lis 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 W;, 40 inches, score 0 points. p� (gasoline) or 10Q (diesel). <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 14 PMi <br /> VI. STAFF RECOMMENDATION/CONCLUSION '` ��� � ` _-•1 40POf <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels *Yes No �. 4- X,4to vim! <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation GtEtJC�j <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 YE5 NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED ! / <br /> NAME OF f <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />