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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTR DIVISION <br /> I. WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME Of FACILITY j SWEEPS CODE' R3 LOCO <br /> ADORESS TANK ID #1,37 - <br /> TANK SIZE FUEL TYP£ <br /> II. GENERAL SITE HISTORY <br /> t** <br /> Is permit current? Yes No Permit # - Facility Status Code Doc.Soil/Gw Cont Yes No <br /> Number of Tanks at facility Age of T s(if avaftable) Type of Tank Steel Fbrgl Sngl Dust <br /> III. TANK HISTORY (14 <br /> Was Tank tested? Yes SI No Failed precision test 7 Yes No 1XIIf yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> was repair dam under inspection? Yes4t�_ <br /> ere soil samples analyzed? Yes No BTXE TPH-G TPH-0 Pb/EDB <br /> Type of failure/discharge catastrophicterm leakage overfill other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soft Samples Received Yes No Depth to Ground Water Ref/Year Average Annual Precipitation Aa 14 10-25 <br /> On-Site WeLt(s) Yes No Number & Type Irr Dom <br /> S Scare S Score S Score <br /> Distance to Wett(s) 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 E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (f t) >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> Average Annual Precipitation Cinches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ) None Present <br /> Unique site features: Recharge area, coarse soft, nearby wells. At Least More than <br /> xxxxxx Norse one one <br /> COLUMN TOTALS»),TOTAL POINTS + + _ <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> B T X E 8 T )LE <br /> MAXIMI ALLOWABLE B-T-X-E LEVELS CPPV) 1 50 50 50 .3 .3 NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> 14AXIMM ALL LE TPN LEVELS CPPM) <br /> TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil 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. wd < 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 STX&E are not appticabte at a TPH concentration of 10 ppm (gasoline) or 100 ppm Cdieset). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable L is *Yes Ho <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 CLOSUIRE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLO=E LETTER MAILED ! ! <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />