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SAN JOAOUIN PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE DIVISION <br />U.st WORKSHEET FOR SITE CLOSURE EVALUATION DATE 3 _ '� - `Z <br />>Ir,ME OF FACILITYgS��o.vl� is SWEEPS CODE /z cS—'=t <br />R.DORESS3?Da l�S�t :, vle' TANK ID "13 1Z�r7' <br />r— <br />TANK SIZE S C FUEL TYPE lJaS O� <br />:. GENERAL SITE HISTORY <br />*** <br />:s permit current? Yes o Permit # - Facility Status Code C%J Doc.Soil/GW Cont Yes No <br />4umber of Tanks at facility Age of Tanks(if available) �� k Type of Tank Steel I 4F6rgL Sngl Dual <br />71. TANK HISTORY <br />4as Tank tested? <br />Yes <br />- <br />No <br />Failed precision test ? es <br />0 <br />No <br />If <br />yes, give date(s) <br />,Was a repair made to the tank system? <br />Yes <br />No <br />If yes, what was repaired? <br />` <br />teas repair done under inspection? <br />i <br />Yes <br />& Type <br />No <br />Irr <br />Were soil samples analyzed? <br />Yes <br />No <br />BTXE <br />Score <br />10 pts <br />if <br />condition <br />is met <br />TPH-G <br />Score <br />9 pts <br />if <br />condition <br />is met <br />TPH-D <br />Score <br />5 pts <br />if <br />condition <br />is met <br />Pb/EDB <br />3� ft; ft; ft <br />Type of failure/discharge <br />,V. Site Feature - Leaching Potential Analysis <br />catastrophic <br />tong -term leakage <br />overfill <br />unknown <br />'-ractures in subsurface (applies to foothills or mountain areas) <br />other: <br />V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received Yes <br />YES <br />- <br />No <br />Depth to Ground Water <br />0 <br />Ref/Year <br />Average Annual Precipitation <br />A= <br />14 <br />10-25 <br />Ion -Site Well(s) <br />YesNoNumber <br />` <br />EVALUATOR <br />, <br />& Type <br />� <br />Irr <br />Dom <br />Pub <br />S <br />C <br />0 <br />R <br />E <br />Score <br />10 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />9 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />5 pts <br />if <br />condition <br />is met <br />!Distance to Well(s) from Tank <br />3� ft; ft; ft <br />,V. Site Feature - Leaching Potential Analysis <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />51-100 <br />25-50\1 <br />'-ractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />Present <br />.average Annual Precipitation (inches) <br />xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />!an -Made conduits which increase vertical migration <br />)f leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />Present <br />:pique site features: Recharge area, coarse soil, nearby wells. <br />xxxxxx <br />None <br />At least <br />one <br />More than <br />one <br />COLUMN TOTALS—TOTAL POINTS <br />r <br />+ <br />3G <br />+ <br />S <br />= y ) <br />Sampie Result: (B T X OjR� E) <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />41 - 48 pts <br />40 pts or less <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />B <br />1 <br />T <br />50 <br />X <br />50 <br />E <br />50 <br />B <br />3 <br />T <br />.3 <br />X <br />1. <br />E <br />1. <br />NA\3 <br />Sample Result: <br />(U TPH <br />GASOLINE <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />DIESEL <br />1000 <br />100 <br />10 <br />10,000 <br />1000 <br />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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />11. STAF= iECOMMENDATION/CONCLUSION <br />1. Are BTX & 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 <br />YES <br />- <br />110 <br />REFERRED TO SITE MITIGATION FOR EVALUATION <br />YES <br />- NO <br />DATE REFERRED <br />/ / <br />DATE CLOSURED,LETTER MAILED <br />/ I <br />NAME OF <br />` <br />EVALUATOR <br />, <br />EH 23 80 (UGTWKSHT)\5/90 i <br />