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SAN JOAQUIN COUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH SIGN <br />I. UG� UORKSHEET FOR SITE CLOSURE EVALUATION DATE <br />NAME OF FAC ILITYVJCP.O SWEEPS CODE <br />1 / <br />ADDRESS Do le�� TANK ID # <br />�V . <br />TANKSIZE/�QOQ FUEL TYPE 1)! e Se' <br />II. GENERAL SITE HISTORY <br />—3— 7r d <br />,L_ <br />5 1/-/- I'D <br />Is permit current? Yes No Permit # - Facility Status Code 0 N <br />Doc.SoiL/GW Cont Yesl No <br />Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br />III. TANK HISTORY <br />IWas Tank tested? Yes X No Failed precision test ? Yes No if yes, <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 PblEDB <br />Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br />tJ TQTnov raTTarm tusuFrTTnN REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received <br />Yes <br />No <br />Depth to Ground Water <br />+JJ U <br />Ref/Year <br />�%� <br />Average Annual Precipitation <br />A= <br />14 10-25 <br />on -Site WeLL(S) <br />Yes <br />No <br />Number & Type <br />Irr <br />Dom <br />I Pub S <br />Score <br />10 pts <br />S <br />C <br />Score <br />9 pts <br />S <br />C <br />Score <br />5 pts <br />if <br />Distance to WeLL(s) from Tank <br />ft; ft; ft C <br />0 <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 />condition <br />is met <br />R <br />V. Site Feature - Leaching Potential Analysis E <br />Minimum Depth to groundwater from the Soil Sample (feet)_(5-�� <br />I >100 <br />I51-100 <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) ` <br />None <br />Unknown <br />Present <br />Average Annual Precipitation (inches) xxxxxx <br /><10 <br />9 <br />10-25 <br />xnxxxxx <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />None <br />Unknown <br />Present <br />of leachate (i.e., septic systems, water wells, ponds) <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />At least <br />More than <br />one <br />xxxxxx <br />None <br />one <br />} <br />+ <br />/' <br />` 0 <br />- 3 <br />0 COLUMN OTALS>>>TOTAL POINTS <br />Sample Rst(B T X OR E) <br />RANGE OF TOTAL POINTS 49 pts or more <br />41 - 48 pts <br />pts or less <br />a <br />T X <br />E <br />B <br />T <br />X <br />E <br />, <br />MAXIMUM ALLOWABLE a -T -X -E LEVELS (PPM) 1 <br />50 50 <br />I <br />50 <br />.3 <br />.3 <br />1. <br />NA\3 <br />Sample Result: <br />GASOLINE 1000 <br />100 <br />10 <br />100 <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />TPH <br />DIESEL 10,000 <br />1000 <br />FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete a eaching pot <br />analysis. (i.e., site is currently on UGT Contamination List for soil or gr we er. <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 />applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />\3 Levels for BTX&E are not <br />VI. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br />2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluati <br />VII REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE <br />YE5 <br />NO <br />REFERRED TO SITE MITIGATION FOR EVALUATION <br />YES <br />NO <br />DATE REFERRED <br />/ / <br />DATE CLOSURE LETTER MAILED <br />1 / <br />NAME OF <br />EVALUATOR <br />H 23 80 (UGTWKSHT)\5/90 <br />