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SAN JOAQUIN PUBLIC HEALTH SERVICES/ENVIRONMENTAL <br /> OUST WORKSHEET FOR SITE CLOSURE EVALUATION N <br /> NAME OF FACILITY DATE �f �� _y <br /> GGo <br /> ADDRESS 3 C SWEEPS CODE / <br /> TANK SIZE �'/��G_ FUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit # <br /> Facility Status Code Yew <br /> Number of Tanks at facility Doc.Soul/GW Cont Yes No <br /> Age of Tanks(if available) <br /> Ilt. TANK HISTORY Type of Tank Steel Fbrgl Sngl Dual <br /> Was Tank tested? Yes No Failed precision test 7 Yes <br /> No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No <br /> If yes, what _­­­ <br /> was rep <br /> Was repair done under inspection? Yes No Were soil sartp les analyzed? Yes No <br /> BT%E TPH•G TPH-D 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 /> Soil Samples Received Yes No Depth to Ground Water Ret/Year q Average Annual Precipitation A= 14 10-25 <br /> On-Site WeLL(S) Yes No Number & Type Irr Dom Pub <br /> .Distance to WeLI(s) from Tank ft; S Score S Score S Score <br /> 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 Soil Sample (feet) >100 51-100 \i 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Gq 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 fj Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None �� one one <br /> i <br /> COLUMN TOTALS>»TOTAL POINTS + 7.� + <br /> Sa le Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> = e-sPoh E- -7 AAS <br /> T �6 /'y7�ry B T X E B T X E <br /> X= 46 ,IV-, MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA%3 <br /> Sample Result: ,E GASOLINE 1000 100 10 <br /> fav PPS >Ptf MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> l/ cy), TPM DIESEL 10,000 1000 100 <br /> FOOTNOTES:------*wtf-documented soil and/or ground 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., scare 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. STAF° 2ECOMMENDATION/CONCLUSION qpJc, <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels -Yes X No II <br /> 7r' V4 rTTr <br /> 2. Recommend Site Closure l Yes No a. •If Yes, 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 i- NO I REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED = / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> 'H 23 80 (UGTWKSHT)\5/90 <br />