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jSIZ5. <br /> SAN JOAQUIH C PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA IVlSIONWORKSHEET FOR SITE CLOSURE EVALUATION . OATSE ACILITY Ar -EPS CODEADDRE �bl �. TANK ID #TANK FUEL 1r: p St <br /> t <br /> II. GENERAL,SITE HISTORY * * <br /> Is permit:current? Yes No Permit iI - Facility Status Code Q oc.Soi Uri Cont No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> Ili. TANK HISTORY <br /> i <br /> Was Tank �tested4 Yes No Failed precision test Tes NoI V1 If yes, give date(s) / <br /> Was a repair made to the tank system? Yes No Vif yes, khat was repaired? N <br /> Was repair done under inspection? Yes o Were soil samples analyzed? Yes BTXE TPH-G TPH-DI WEDS <br /> Type of failure/discharge ca strophic Long-term leakage overfill mimwn other: <br /> IV. REMOVAL HISTORY (ATTACH IHS CTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> SoiL Samples Received Yes No Depth to Ground Water 1j)1 I Ref/Year ; �j� Average Annual Precipitation A=114 10-25 <br /> On-Site WeLL(s) Yes L* o Number & Type Trr Dam Pub <br /> S Scare S Scare 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)—S l Z >100 151-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) Hone Unknown Present <br /> Average Annuai Precipitation (inches) xxxxxx <10 i 9 10-25 xxxxxxx 26-40\2 <br /> Nan-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 watts, At Least More than <br /> xxxxxxl None one one <br /> COLUMN TOTALS>»TOTAL POINTS + + ' <br /> Samplesuit• (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> KNY) 5�+•�Fe� <br /> r 1pfN: 4 i.lQgM 11 •`,S B T I X I E B IT X E <br /> 1•g m } 5 k. AeiA:F�'., MAXIMUM ALLOWABLE 8-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. I. MA\3 <br /> Sample Resutt: GASOLINE 1000 100 10 <br /> Zq) '-G:; I^^ MA IMUM ALLOWABLE TPR LEVELS (PPM) <br /> TPN DIESEL 10,000 1000 i00 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not comptete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> < ore 0 points. If depth �5 ft. do riot use table.. <br /> \i If depth is > 5 ft. and 25 ft., score po eP <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concen ,tion of 10 ppm (gasolli_n-e) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> QQ � <br /> Com" <br /> f'� <br /> 1. Are 8TX & E or TPH Concentrations > Ail able Levels *YesNo i �p '� T <br /> 2. Recommend Site Ctosure Yes No V *If Yes, Refer to Site Mitigation for Evatuation <br /> VTI. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YE5 HO REFERRED TO SITE MITIGATION FOR EVALUATION YE5 NO <br /> DATE REFERRED /j / DATE CLOSURE LETTER MAILED <br /> NAME OF n . <br /> EVALUATOR U <br /> EH 23.80 (UGTWKSHT)\5/90 <br />