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SAN JOAOUIN iTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEDIVISION <br /> 1 GST WORKSHEET FOR SITE CLOSURE EVALUATION � ATE C <br /> AME OF FACILITY �I <br /> SWEEPS CODE <br /> DDRESS (� TANK 10 # <br /> TANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> :r <br /> is permit current? Le <br /> so ermit ft acility Status Code oc.SoiL/GW Cont es o <br /> umber of Tanks at facility %ge of Tanks(if available) I IType of Tank ISceel Fbrgi I 1Srg1 I Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? Yes No 11f yes, what was repaired? <br /> ns repair done under inspection? es 40 ere soil samptes analyzed? es 10 TXE IT <br /> PH•G I IT <br /> PH-D b/EDB <br /> ype of faiture/discharge atastrophic Long-term leakage verfitI nknown Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .oil Samples Received es o epth to Ground water jL of/Year j�(2� ; verage Arcual Precipitation = 4 110-25 <br /> -Site Wett(s)Fe7s o I umber & Type Irr cm ub <br /> S Score S Score S Score <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C5 pts <br /> 0 if 0 if 0 •f <br /> R ondition R condition R ondition <br /> 0. Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inirtwm Depth Lo groundwater from the Soit Sample (feet) j`���G,� >100 1-100 25.50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) j None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 Kxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown DIresent <br /> Inique site features: Recharge area, coarse soil, nearby wells. q At Least 4ore than <br /> xxxxx None [ one one <br /> COLUMN TOTALS>>>TOTAL POINTS + [ ( + 3-3 <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> L -a' B T % E 8 I X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> 'ample Result: ASOLINE 1000 100 10 <br /> C),� AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> �'m TPN IESEL 10,000 1000 100 <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 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, scare 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION I <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o ��¢.��L�'�� ✓ c �� <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE CCMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES1 0 EFERRED TO SITE MITIGATION FOR EVALUATION fES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />