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SAN JOAQUIN UMV PUBLIC HEALTH SERVICES/ENVIRONMENTAL H DIVISION _ <br /> I. WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY ® o SWEEPS CODE <br /> ADDRESS TANK ID $ <br /> TANK SIZE Z-W j FUEL TYPE + <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit - (Facility Status Code Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facilityl Age of Tanks(if available) (Type of Tank Steel Fbrgl Sngl Oual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No If yes, give dates) <br /> Was a repair made to the tank system?IYes No if yes, what was repaired?` <br /> Was repair done under inspection? Yes No IWere soil samples analyzed? Yes No ME TPH-G ITPH-0I Pb/EDB <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 Ref/Yearl Average Annual Precipitation A= 14 10-25 <br /> On-Site Wells) Yes No Number & Type Irr Dom IPub) <br /> S Score S Score S Score <br /> Distance to Wells) 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 mete is met E is met <br /> (Minimum Depth to groundwater from the Soil Sample (feet) >100 I I51-100 125-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None I Unknown I (Present <br /> 1Average Annual Precipitation (inches) xxxxxxl <10 I 9 110-25 (xxxxxxx) 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None I Unknown (Present <br /> jUnigue site features: Recharge area, coarse soil, nearby wells. At least) More than <br /> xxxxxx None one one <br /> P COLUMN TOTALS>>>TOTAL POINTS 4. I <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 11 50I 50 50 I .3 J. <br /> I <br /> 1. 1. NA\3 <br /> Sample Result:. GASOLINE 1000 100 I 10 <br /> MAXIMUM WLLOWABLE TPH LEVELS (PPM) <br /> rPH DIESEL 10,000 I 1000 I 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 STUE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yesl INo 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 IYESI NOI IREFERRED TO SITE MITIGATION FOR EVALUATION I YESI IN0' <br /> DATE REFERRED( IDATE CLOSURE LETTER MAILED i <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />