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SAN JOAQUINY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE IVISION <br /> I. OST WORKSHEET FOR SITE CLOSURE EVALUATICN DATE I %_ <br /> / SWEEPS CODE L <br /> (NAME Of FACILITY I `� �!/� ; y� o <br /> (ADDRESS I e. c id a ` In/f� in I'� C> 1 ,!/,'Li /—/14- 1�'/f�TANK ID <br /> (TANK SIZE j✓1 �rn FUEL TYPE( �^ <br /> [I. GENERAL SITE HISTORY <br /> Is permit current?IYes I Nof Permit 9 - (Facility Status Codel ' IDoc.Soil/GW ContlY s No X <br /> Numcer of Tanks at facility) Age of Tanks(if available) Type of Tank Steel Fbrgl Sngll Dual <br /> III. TANK HISTORY <br /> Was Tank tested?IYes NoI (Failed precision test ? Yes No If yes, give date(s) <br /> Was a repair made to the tank system7IYes No� �IIf yes, what was repaired? <br /> Was repair done under inspection? YesINaI (Were soil samples analyzed? Yes) INoI BTXEI TPH-GI TPH-D IPb/EDB <br /> Type of failure/discharge) catastrophic long-term Leakage Ioverfill unknown Iother: <br /> IV. .REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received IYes NoI (Depth to Ground Water- j7G, Ref/YearI Average Annual Precipitation IA= 14 10-25 <br /> On-Site Wetl(s) Yes No I Number & Type) Iirrl IDomI Pub! <br /> S Score S Score S Score <br /> Distance :o WeLL(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 /> V. Site Feature - Leaching Potential Analysis _ is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet)} - ! >100 I51-100 I 125-50\1 j <br /> Fractures in subsurface (applies to foothills or mountain areas) , !�1 None Unknown (Present <br /> (Average Annual Precipitation (inches) xxxxxxl <10 I 9 1 10-25 Ixxxxxxxl 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> ,of Leachate (i.e., septic systems, water wells, ands) I None l Unknown ( Present <br /> (Unique site features: Recharge area, coarse soil, nearby wells. I I I At least) (More than <br /> xxxxxx None one (III one <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> i <br /> Sample Result: <br /> // (3 T X OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 - 48 pts I 4D pt <br /> B T X I E 3 T A X � EI <br /> MAXIMUM ALLOWABLE 3-7-X-E LEVELS (PPM) 1 50I SOI 50 I .3 I.3 1.I 1. kl 'Z <br /> NA\3 <br /> Sample Result: GASOLINE 1000 I 100 I 10 <br /> �1J MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 I 1000 100 I i <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the Lea. :a <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 < 3 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> i \3 Levels for 3TX&E are not applicable at a TPH concentration of i0 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are 3TX & E or TPH Concentrations > Allowable Levels I*Yes NoI <br /> 2. Recommend Site ClosureiYesJl No *If Yes, Refer to Site Mitigation for Evaluation )C e �1 <br /> J <br /> VII. REVIEW EVALUATION - TO 3E COMPLETED 3Y A SUPERVISOR/SENIOR Y, K <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYESI INOI (REFERRED TO SITE MITIGATION FOR EVALUATIONIYESI INOI � C <br /> DATE REFERRED( / / DATE CLOSURE LETTER MAILEDI / / <br /> NAME OF <br /> EVALUATOR I <br /> EH 23 11 (UGTWKSHT)\5/90 <br />