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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I. A&ST WORKSHEET FOR SITE CLOSURE EVALUATION AM DATE /-- <br /> NAME OF FACILITY ® EPS CODE <br /> ADDRESS ®LZ.,a l4ANK ID # - <br /> TANK SIZE aQ FUEL TYPE I e <br /> II. GENERAL SITE HISTORY <br /> oars <br /> Is permit current? Yes No Permit # Facility Status Code Doc.Soil/GW Cart Yes Na <br /> Number of Tanks at facility Age of T (if available) Type of Tank Steel Fbrgl Sngt Dual <br /> I1I. 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? YesNo Were soil samples analyzed? Yes No BTXE TPH-G TPH•0 Pb/EDB <br /> Type of faiture/discharge catastrophic loV•term leakage overfill 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 WaterRef/Year ; Average Annual Precipitation As 14 10-25 <br /> On-Site Wells) Yes No Number & Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to Well(s) frac Tank I 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 (feet) >100 51-100 25.50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ) Nona Unknown Present <br /> Unique site features: Recharge area, coarse soft, nearby welts. 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 49 pts or more 41 . 48 pts 40 pts or less <br /> B T X E 6 T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIML04 ALLOWABLE TPH LEVELS (PPM) <br /> TPN DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the teaching 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 TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> Vt. STAFF RE ENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes Z 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 VIM01 <br /> DATE REFERRED / / DATE CLOSUR LET ER MAILED ! / <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />