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SAN JOAAUtH COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH nIVYStON <br /> I.rWORKSHEET FOR SITE CLOSURE EVALUATION DATE —7-13 <br /> 4 <br /> ,NAME OF FACILITY Si+EEPS CODE <br /> ADDRESS a ) TANK ID # - .® <br /> TANK SIZE I FUEL TYPE e <br /> II. GENERAL SIA HI ORY <br /> Is permit current? Yes No Permit # Facility Status Code Doc.Soit/GW Cont Yes No <br /> Number of Tanks at facnlity Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No If yes, give date(s) o" ! <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? rtr c . <br /> Was repair done under inspection? Yes No Were soil samptes analyzed? Yes No II-BTXE TP -G TPH-D JE <br /> Pb/EDB <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 /> Soft Samples Received Yes No Depth to Grand Water Ref/Year ; Average Annual Precipitation Aa 14 10-25 <br /> On-Site WeLL(s) Yes No Number & Type1:1 Irr Dam Pub <br /> S Score S Score S Score <br /> Distance to Welts) 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 Soft 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 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water welts, ponds) Nam Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None ons one <br /> COLUMN TOTALS»>TOTAL POINTS t t a <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> ILE 8 T X MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH DtELJ <br /> 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or grand 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. 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 (dieset). <br /> Vt. STAFF RECOMMENDATION/CONCLUSION c <br /> 1. Are BTX & E or TPH Concentrations > Allowable levels *Yes No <br /> 2. Recommend Site Closure YesNo *If Yes, Refer to Site Mitigation for Evaluation ZA <br /> c <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> _-TCONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES I NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED / ! <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />