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SAN JOAOUIN TY PUBLIC HEALTHSERVICES/ENVIRONMENTAL Ii DI V[ SI ON <br /> I . .GST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY - Owl. fV SWEEPS CODE - <br /> f{ ADDRESS '7G, Q G � yv TANK ID #.0 ? <br /> TANK SIZE75 ` FUEL TYPE �� S© b- �_ / <br /> II . GENERAL SITE HI RY +-ts <br /> i <br /> Is permit current? Yes No Permit # - Facility Status Code Doc . Soil /GW Cont Yes No <br /> j Number of Tanks at facility Age of Tanks ( if available) Type of Tank Steel Fhrgl sngl Duat <br /> i <br /> i <br /> 111 . TANK HISTORY <br /> Was Tank tested? Yes INX FaiLed precision test ? Yes No If yes , give date( s ) <br /> i <br /> Was a repair made to the tank system? Yes No It yes , what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH- G TPH - D Pb/EOB <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 3 d Ref/Year O Average Annual Precipitation A= 14 10- 25 <br /> On-Site WeLL ( s ) Yes No Number 8 Type Irr Dom Puh <br /> S Score S Score S Score <br /> Distance to Well ( s ) from Tank ft ; ft ; ft C 10 pts C 9 pts C 5 pts <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 ) _6 .-. >100 51 - 100 Q 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 soil , nearby wells . At Least More than <br /> xxxxxx None one one <br /> "'xhae COLUMN TOTALS>>>TOTAL POINTS _ <br /> Sample Resu t : ( e T X OR E ) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> f3 = p Co E E5 7, <br /> Q v B T X E B T X E <br /> /"' �' 3 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 <br /> TP f4JG � 50 MAXIMUM ALLOWABLE TPN LEVELS ( PPM ) <br /> 1 I <br /> TPH DIESEL 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 , 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 RECOMMENDATION/CONCLUSION � S <br /> 1 , Are BTX 8 E or TPH Concentrations > Allowable Levels *Yes No <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 <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES - NO REFERRED TO SITE MITIGATION FOR EVALUATION YES I 1A <br /> NO <br /> DATE REFERRED DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT )\5/90 <br />