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f f SAN JOAOUIN GY PUBLIC HEALTH SERVICES/ENVIRONMENTAL, HEI ^IVISION <br /> q L' WORKSHEET FOR SITE CLOSURE EVALUATION <br /> /J 4 <br /> NAME OF FACILITY /\� SWEEPS CODE 3 <br /> ADDRESS6z le"Q441 61 <br /> C TANK ID # 3 5A r <br /> TANK SIZE FUEL TYPE <br /> GENERAL SITE HISTORY 1 <br /> Is permit current? Yes No Permit # - Facility Status Code �i Doc.Soil/GW Cant Yes No <br /> Number of Tanks at facility ; Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> I. TANK HISTORY <br /> 'Jas Tank tested? Yes No Failed precision test ? Yes No If yes, give date(s) <br /> Jas a repair made to the tank system? Yes No If yes, what was repaired? <br /> Jas repair done under inspection? Yes Nol Were sait samples analyzed? Yes No BTXE TPH-G TPH-D Pb/ED8 <br /> ype of failure/discharge catastrophic long-term leakage i overfill unknown other: <br /> REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .oil Samples Received Yes Y <br /> No Depth to Ground Water Ref/Year g� ; Average Annual Precipitation A= <br /> ,n-Site Well(s) Yes No [Number $ Type 14 10-25 <br /> Irr Dom Pub <br /> S Score S Score S Score <br /> ,istance to Welt(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R conditionj R Icondition R condition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sampte (feet) >100 I 51-300 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) � , None Unknown Present <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown Present <br /> iique site features: Recharge area, coarse sail, nearbywells. s <br /> At least More than <br /> xxxxxx None one one <br /> 1 IO ' <br /> COLUMN TOTALS»>TOTAL POINTS ! D + _ <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts: or more 41 - 48 pts 40 pts or less <br /> TSC A- 8 f�o <br /> SA. ptf' i3 = B T x E B x EMAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 I.T <br /> 3 1. 1. NA\3 i <br /> mple es t: GASOLINE 1000 100 1Q <br /> y TWO <br /> ..r MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TP O— rn DIESEL 10,000 � 1000 100 <br /> i <br /> OTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching po Tal <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 (gasoline) or 10Q diese <br /> ppm ppm ( i). <br /> STAFF RECOMMENDATION/CONCLUSION <br /> 8o c x f i e— s A • Ie sZFeU <br /> i <br /> Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br /> Recommend Site Closure Yes No *if Yes, Refer to Site Mitigation for Evaluation IS 5 a- <br /> REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/ NIOR a. � � �.� Pr <br /> DNCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATIONiYES <br /> ITE REFERRED / / TE CLOSURE L TTER MAILED <br /> IME OF <br /> IALUATOR <br /> 1 23 80 (UGTWKSHT)\5/90 <br /> . i <br />