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SAN JOAQUINY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE DIVISION <br /> I. T WORKSHEET FOR SITE CLOSURE EVALUATION [DATE <br /> NAME OF FACILITY ♦ SWEEPS CODE <br /> ADDRESS l TANK ID # - <br /> TANK SIZE FUEL TYPE o'r L <br /> II. GENERAL SITE HISTORY <br /> *** <br /> Is permit current? Yes o Permit # - Facility Status Code Doc.Soit/GW Cont YesNo <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No If yes, give date(s3 <br /> Was a repair made to the tank system? Yes No If yes, what was,repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPH-0 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 ` f Ref/Year ; iq Average Annual Precipitation A= 14 10-25 <br /> On-Site Wells) Yes Noi Number & Type Irr Dan Pub <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 QT' E is met E is met E is met <br /> Minimum Depth to groundwater frau the Soil Sample (feet) I-Ir >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknowrei Presen <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-AA <br /> xxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water welts, ponds) None known Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS»)TOTAL POINTS + + _ <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 4%/pots or more 41 - 48 pts 40 pts or less <br /> MO 003 <br /> NA o0$ B T X E B IT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> �SPmp�le�Ree jLt: GASOLINE 1000 100 10 <br /> N' P MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH 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 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 /> VI. STAFF RECOMMENDATION/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 YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED / f <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />