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SAN JOAOUIN CoPURLIC HEALTH SERVICES/ENVIRONMENTAL HEAWIVISION <br /> 1' t THEET FOR SITE CLOSURE EVALUATION _ <br /> DATE <br /> NAME OF fAC[IITY <br /> SWEEPS CODE <br /> ADDRESS /S00 n/ 1 / `„� <br /> TANK <br /> CJ / ID # O <br /> TANK SIZE bO O FUELL 40 TYPE D `Q <br /> 11, GENERAL S E HISTORY <br /> !s permit current? Yes No Permit # _ *** <br /> Facility Status Code Doc.Soil/CW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Duel <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? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPH-D Pb/E08 <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soit Samples Received Yes No Depth to Ground Water Ref/Year �� Average Arcual Precipitation A-114 10-25 <br /> On-Site Welts) Yes x No Number i Type irr Dom Pub , <br /> Distance to Wells) from Tank ft; ft; ft S Score S Score S Score <br /> 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)�b.,. (�=3 >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) t d None Unknown Present <br /> Average Annual. Precipitation (inches)- 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, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby welts. Q At least More than <br /> xxxxxx None f one one <br /> COLUMN TOTALS>>>TOTAL POINTS , V + + + - 3F <br /> Sample Result: (8 T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> Tf F =Ni) <br /> B T X E B T X E <br /> I u) :: ty Q 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 /> /4 /1 V h MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> V 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. (1.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 /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allbwable levels *Yes INo <br /> 2. Recommend Site Closure Yes No If Yea, 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 7RTFERRED 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 />