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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> 1' UG! ORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY - SWt,S CODE <br /> ADDRESS <br /> TANK ID # - <br /> TANK SIZE 3, (,;;�:J FUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> eef <br /> Is permit current) Yes No Permit # - Facility Status Code Doc.SOII/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank SteeL FbrgL1 Sngl Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 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 Pb/EDB <br /> Type of failure/discharge catastrophic Lang-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL A)ALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water Ref/Year Average Annual Precipitation A• 14 10-25 <br /> On-Site WeLI(s) Yes No Number S Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to 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 E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None -J Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxaxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> rof leachate (i.e., septic systems, water rolls, prods) None Unknown Present <br /> (Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> �G �rTh66T A. L- <br /> COLUMN TOTALS>>>TOTAL POINTS + + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> 15At.0. .oi O9a E= dor <br /> 8 T X E B T X E <br /> MAXIMALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPN - DIESEL 10,000 1000 100 <br /> FOOTNOTES: —if documented soil and/or grand water contamination is present, do not ccaplete 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 rot use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX8E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX S E or TPH Concentrations > Allowable Levels 'Yes Na <br /> 2. Recommend Site Closure)Yes No� If Yes, Refer to Site Mitigation for Evaluation) <br /> VII. .REVIEW EVALUATION - TO BE COMPLETED 3T A SUPERVISOR/SENIOR <br /> CCNCJR WITH STAFF RE="ENDATICN FOR CLOSUREIYES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES( Rai <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAMECF <br /> EVALUATCRI <br /> EH Z3 80 (UGTWKSHT)\5/90 <br /> GG e SiJrJ/ VG 8vzm u/Js n/vi e� mJ.F>eo �j c4 Z' <br />