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SAN JOAQUIN TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H, H DIVISION — <br /> I ..3ST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAM E OF FACILITY — f� SNEEPS CODE - <br /> ADDRESS 7 - , !'Y(:G�i'i/�-t. QG TANK TD # ' <br /> TANK SIZE75 ) - FUEL TYPE Lf <br /> II . GENERAL SITE HISTdRY <br /> *** <br /> - Facility Status Cade q Doc . Soil/GW Cont Yes <br /> Is permit current? Yes No Permit # No <br /> Number of Tanks at facility Age of Tanks ( if available ) 4Yh,rti Type of Tank Steel Fbrgt SngL Dual <br /> III , TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No If yes , give date( s) <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 BTXE TPH - G TPH -D Pb/EDB <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 Received Yes No Depth to Ground Water Ref/Year � cd ; Average Annual Precipitation L <br /> On-Site WeIL ( s ) Yes No Number & Type Irr DomHPub <br /> S Score S Score S <br /> Distance to WeIL ( s ) from Tank ft; ft ; C 10 pts C 9 pts C <br /> 0 if O if C <br /> R condition R condition R V . Site Feature - Leaching Potential Analysis E is met E is met E Minimum Depth to groundwater from the Soil Sample ( feet ) v — >100 51 - 100 - \ <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 0 , e , , septic systems , water wells , ponds ) None Unknown Present <br /> Unique site features : Recharge area , coarse soil , nearby wells . At least More than <br /> v��^^ xxxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> Sample Resul :_ ( e T X OR E ) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> 49 L03 - � do B T X E B T X E <br /> )( � Od <br /> MAXIMUM ALLOWABLE B -T - X- E LEVELS ( PPM ) 7 50 50 50 .3 . 3 1 . 1 . NA\3 <br /> Sample Result : GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS ( PPM ) <br /> 3 (� (� TPH G� DIESEL 10 , 0011 1000 100 <br /> ter contamination is present , do not complete the leaching potential <br /> FOOTNOTES : *** If documented sail and/or ground wa <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, 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 ,SG <br /> 1 . Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br /> 2 . Recommend Site Ll osure YesJ <br /> No * 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 REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / '5/t, / (5 ' DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT) \5/90 <br />