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SAN JOAQUIN Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEDIVISION <br /> I qT WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY SWEEPS CODE <br /> ADDRESS S ` TANK ID # 5 <br /> G <br /> TANK SIZE FUEL YPE <br /> kG-f�k� "�bvnb 31}r V-5 Ga�r�r�{'�c�c{=�� CSC f i i t'+-,c5 i <br /> LI. GENERAL SITE HISTORY <br /> *** <br /> Is permit current? Yes No Permit # - FaciLity Status Code Doc-Soil/GN Cont Yes No <br /> a <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sin L Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes Na J Failed precision test ? Yes No If yes, give dates) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done 'under inspection? Yes No Were soil samples analyzed? Yes No BTXETPH-G TPH-D Pb/EDS <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples ReceivedYes F No Depth to Ground Water Ref/Year overage Annual Precipitation A= 14 10-25 i <br /> On-Site Wel (s) Yes No Number & Type Irr Dom Pub <br /> S Score 5 Score 5 Score � <br /> Distance to WeLI(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if O 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 sot[ Sample (feet) >100 57-100 � 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 <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse sail, nearby wells. <br /> At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + �1 _ + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 4411 48 pts 40 pts or less <br /> I <br /> B T X 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 /> Sample Result: GASOLINE 1000 100 10 i <br /> I MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> G• l TPH ' DIESEL 10,000 1009 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.) I <br /> \1 If depth is > 5 ft. and < 25 ft., scare 0 points. If depth <=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 /> SILL L .1 <br /> 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR k <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YE5 VINC11 REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED / <br /> NAME OF ` <br /> EVALUATOR { <br /> EH 23 BO (UGTWKSHT)\5/90 <br /> y � <br />