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SAN JOAQUINY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H DIVISION <br /> 1. Sr WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY y SWEEPS CODE, <br /> ADDRESS � <br /> TANK SIZE FUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> * <br /> Is permit current? Yes No Permit - Facility Status Code Doc.SOil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) /f Type of Tank Steel Fbrgl Sngl Duat <br /> I11. TANK HISTORY <br /> Was Tank tested? Yes , No Failed precision test ? Yes No If yes, give dates) <br /> ,Was a repair made to the tank system? as No if yes, what was repaired? <br /> Al <br /> was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPN-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown Lother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soit Samples Received as No Depth to Ground Water Ref/Year Average Annual Precipitation EE10-:25: <br /> !On-Site Wells) Yes No Number & Type Irr Dan Pub <br /> S Score S Score S Score <br /> :Distance to WeII(s) 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 /> 1V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet)')&- .a >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 migrati <br /> of leachate (i.e., septic systems, water wells )� None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby welts. At least More than <br /> xxxxxx None one ____ one <br /> COLUMN TOTALS»>TOTAL POINTS � �/' + / + <br /> m <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts <br /> ` t ' B T X E B T X1 r <br /> IMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> f �1 I ALLQ4IABLE TPH LEVELS (PPM) <br /> t TPH D DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the tea testi <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 /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes'X1101 I G1° r/ . 1 <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation ��" ° ! � " <br /> C a ° C r <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED ! / DATE CLOSURE LETTER MAILED <br /> NAME OF 1 <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />