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J <br /> I ' <br /> I <br /> / SAN JOAOUIN CCLr'�JBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH ION <br /> UCI ZRKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> ,+E OF FACILITY �< ��A SWEEPS CODE y 7 <br /> � <br /> �Fj �ew~ S TANK ID ! <br /> ADORESSI <br /> TANK SIZE Li sZj <br /> FUEL TYPE we <br /> GENERAL SITE HISTORY ... <br /> Is pernit current? Yes No Permit >t - Facility Status Code Dae.Soil/CY Cont Yez No <br /> Number of Tanks at facility Age of Tanks(if available) U N 1 Type of Tank Steel Fbrgl Sngl Dual <br /> 'I. TANK HISTORY <br /> 'Was Tank tested? les No led precision test 7 Yes No If yes, give <br /> ai <br /> Was a repair made to the tank system? Yes No yes, what was repaired? <br /> !Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPN-G ITP!-]D Pb/EDB <br /> iType of failure/discharge catastrophic long-term leakage overfill unknown other: <br /> V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Yater IJ Ref/Year Sr6; Average Arr"al Precipitation A= 14 10-25 <br /> On-Site WeIL(s) Yes No umber & Type Irr Dam Pub S Score S Score S Score <br /> Distance to WeLI(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts i <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V- Site Feature - Leaching Potentiat Analysis E is met E is met E is met <br /> MinimDepth to groudwater from the Soil Semple (feet) ),100 51-100 0 25.Minimum <br /> li <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 /> i <br /> Man-Made conduits which increase vertical migration None Ups Present <br /> of leachate (i.e., septic systems, water wells, ponds) /� i - I <br /> Unique site features: Recharge area, coarse soil, nearby wells. At Least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS»),TOTAL POINTS 2 ~ * 3 <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> Aln 8 T X E B T X E <br /> if MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. MA\3 <br /> Sample Result GASOLIME 1000 100 10 <br /> MAXIMUM ALLOYAILE TPN LEVELS (PPM) <br /> O TPN 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 we table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 levels for BTXLE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX L E or TPN 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 NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILEDE - <br /> NAME OF <br /> EVALUATOR <br /> \.-e <br /> EX Z3 80 (UGTWKSHT)\5/90 <br />