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SAN JOAGUIN PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE'A@hMLVISIOM <br /> I. WORKSHEET FOR SITE CLOSURE EVALUATION DATEI /4!;7 <br /> NAME OF FACILITY I SWE=PS COOE� 93 17 <br /> ���f_ <br /> ADDRESS �^ TANK ID # <br /> TANK SIZE / FUEL TYPE <br /> 1I. GENERAL SITE HISTORY <br /> uyrs <br /> Is permit current? Yes No Permit # - Facility Status Code Doc.Soit/GW Cant Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgt Sngl Duat <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection?I Yes No Were sail samples analyzed? Yes No STXE ITPH-G LPH-OF Pb/EDB <br /> Type of failure/discharge catastrophic hong-term leakage overfill Iunknown Iother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> SoiL Samples Received IYes No Depth to Ground Water Ref/Year Average Annual Precipitation A= 14 10-25 <br /> On-Site Wells) Yes No Number & type irr Dom 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 E is met is met E is met <br /> Minimum Depth to groundwater from the Soil Sampte (feet) I >100 I 1 51-100 I 125-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) I None Unknown (Present <br /> Average Annual Precipitation (inches) xxxxxxl <10 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 Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. ` At least More than <br /> xxxxxx None ! ane one <br /> COLUMN TOTALS»>TOTAL POINTS + + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more i 41 - 4a pts I 40 pts or less <br /> B T X E 3 JT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) t 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> 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) IREFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />