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SAN JOAQUIN SY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEADIVISION <br />I UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br />(NAME OF FACILITY �L i S SWEEPS CODE <br />!ADDRESS TANK ID # <br />TANK SIZE �(fp IFUEL TYPE ?i►.��zf <br />II. GENERAL SITE HISTORY <br />is permit current? Yes I <br />Number of Tanks at facility <br />III. TANK HISTORY <br />Permit # Facility Status Code�� Doc.SoiI/GW Cont Yes N <br />Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br />,Was Tank tested? <br />Yes <br />V <br />No <br />Failed precision test ? <br />Yes <br />No <br />If yes, give date(s) <br />A= <br />.Was a repair made to the tank system? <br />Yes <br />No <br />Yes <br />If yes, what was repaired? <br />No <br />Was repair done underinspection? <br />Yes <br />No <br />Were soil samples analyzed? <br />Yes <br />INo <br />S <br />C <br />BTXE <br />TPH-G <br />TPH-D <br />S <br />C <br />Pb/EDB <br />;Type of failure/discharge <br />catastrophic <br />long-term leakage <br />overfill <br />unknown <br />0 <br />R <br />E <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACMINu NUMNiIAL ANALTJIaj <br />Soil Samples Received <br />Yes <br />No <br />Depth to Ground Water <br />Ref/Year <br />Average Annual Precipitation <br />A= <br />14 <br />10-25 <br />on -Site Well(S) <br />Yes <br />No <br />Number & Type <br />Irr <br />Dom <br />Publ <br />S <br />C <br />Score <br />10 pts <br />S <br />C <br />Score <br />9 pts <br />S <br />C <br />Score <br />5 pts <br />jDistance to WeII(S) from Tank <br />ft; ft; ft <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />V. Site Feature leaching Potential Analysis <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />a <br />51-100 <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />None <br />N <br />Unknown <br />Present <br />Average Annual Precipitation (inches) <br />xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />IMan-Made conduits which increase vertical migration <br />Unknown <br />Present <br />lof leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />None <br />At least) <br />one <br />More than <br />one <br />xxxxxx <br />+ <br />'L <br />+ <br />�� <br />=3 <br />COLUMN TOTALS»>TOTAL POINTS <br />'Sample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />41 - 48 pts <br />40 pts or less <br />B <br />TX <br />E <br />8 <br />T <br />X. <br />E <br />I <br />I y <br />N <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />1 <br />50 <br />501 50 <br />.3 <br />.3 <br />1 <br />1. <br />NA\3 <br />I <br />;Sample Result: <br />GASOLINE <br />1000 <br />100 <br />10 <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />1000 <br />100 <br />TPH <br />DIESEL <br />10,000 <br />;FOOTNOTES: ***If documented soil and/or ground water contamination Is present, UV Uva <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 />41. STAFF RECOMMENDATION/CONCLUSION <br />_ IT <br />1. Are BTX & E or TPN Concentrations > Allowable Levels *YesNo V <br />2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation <br />.. 5ev1eU cve11ierrn161 - Tn ar rnmptETEn RY A SUPERVISOR/SENIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br />DATE REFERRED / / DATCLOSURE LETTER MAILED <br />NAME OF nn nn v <br />EVALUATORI <br />=u of nn r11r.Tu1ee14T)X5ion <br />