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SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br />i. WORKSHEET FOR SITE CLOSURE EVALUATIONDATE <br />NAME OF FACILITY f r tTA <br />CODE 3 <br />ADORES$ �C�' �' # - _. <br />a <br />TANK SIZE a JT fWEt TYPE <br />*** <br />n permit current? Yes No Permit # - g Facility Status Corte O , Doc.Satt/GW Cont Yes ` No <br />tuber of Tanks at facility Age of Tanks(if available) .A -7 Type of Tank Steel KA Fbrgl I Sngl Dual <br />TANK HISTORY <br />Was Tank tested? <br />Yes <br />No <br />Failed precision test ? <br />Yes11 <br />No <br />If <br />yes, give date(s) <br />Was a repair made to the tank system? Yes No <br />if yes, what was repaired? <br />Yes <br />Was repair done under inspection? Yes No Were soil samples analyzed? <br />Yes <br />No <br />BTXE <br />TPN -G <br />TPH-O <br />Pb/EDB <br />Type of failure/discharge <br />Pub <br />catastrophic tang -term leakage <br />Score <br />10 pts <br />if <br />condition <br />is met <br />overfill <br />Score <br />9 pts <br />if <br />condition <br />is met <br />unknown <br />Score <br />5 pts <br />if <br />condition <br />is met <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received Yes <br />No <br />Depth to Ground Water <br />Ref/Year <br />&; <br />Av@rage Annual Precipitation <br />As <br />14 <br />10-25 <br />On -Site Wel((s) <br />Yes <br />No <br />Number & Type <br />Ir ;I <br />Ona <br />Pub <br />S <br />Score <br />10 pts <br />if <br />condition <br />is met <br />$ <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 Welts) from Tank <br />ft; ft; ft C <br />o <br />R <br />V. Site Feature - Leaching Potential Analysis E <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />3,100 <br />51.100 <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />Present <br />Average Annual Precipitation (inches) xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />Present <br />Unique site features: Recharge area, coarse soil, nearby welts. <br />xxxxxx <br />None <br />At least <br />one <br />More than <br />am <br />COLUMN TOTALS>>3,TOTAL POINTS <br />♦ <br />♦ <br />: <br />Sample Result: (8 T X OR E) RANGE OF TOTAL POINTS 49 pts or more <br />8T X E <br />MUM AXIMALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 50 <br />41 - 48 pts <br />40 pts or less <br />B IT X E <br />.3 .3 1. 1. <br />NA\3 <br />Sample Result: <br />TPN <br />GASOLINE <br />MAXIMUM ALLOWABLE TPH LEVELS (PPN) <br />DIESEL <br />1000 <br />100 <br />10 <br />10,0001000 <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 anUGT Contamination List for soil or ground water.) <br />\1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <:S ft., do not use table. <br />\2 if precipitation is > 40 inches, score 0 points. <br />\3 Levels for BTX&E are not appticable at a TPN concentration of 10 ppa (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX & E or TPN Concentrations > Allowable Levels *Yes No <br />2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evatuati <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 / I DATE CLOSURE LETTER MAILED <br />NAME OF <br />EVALUATOR <br />EN 23 80 (UGTWKSHT)\5/90 <br />