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SAN JOAQUIN C 'Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA' DIVISION <br />I �%mXiT WORKSHEET FOR SITE CLOSURE EVALUATION -.f <br />NAME OF FACILITY <br />SWEEPS CODE <br />ADDRESS 35 C �` <br />.7 TANK ID k - <br />TANK SIZE ?�� FUEL TYPE Kp <br />II. GENERAL SITE HISTORY <br />Is permit current? <br />Yes <br />No <br />Permit 9 <br />- <br />Facility Status Code <br />4 <br />Doc.SoiI/GW Cont <br />Yes <br />/31 <br />No <br />Yes <br />Number of Tanks at facility <br />D <br />Age of Tanks(if a"itable) <br />Was repair done under inspection? <br />Type of Tank <br />Steel <br />No <br />FbrgL <br />Were sail samples ana lyzed7 <br />Sngl <br />S <br />C <br />0 <br />R <br />E <br />Duel <br />l I <br />Ill. TAMC HISTORY <br />Was Tank tested? <br />Yes <br />No <br />Fai Led precision test 7 <br />Yes <br />WNo <br />DATE CLOSURE LETTER !AILED <br />If <br />yes, give date(s) 17 <br />/31 <br />Was a repair made to the tank system! <br />Yes <br />No <br />If yes, what was repaired? <br />Tn &Q� Z A-, <br />Was repair done under inspection? <br />Yes <br />Irr <br />No <br />Doo <br />Were sail samples ana lyzed7 <br />Yes <br />S <br />C <br />0 <br />R <br />E <br />No <br />S <br />C <br />0 <br />R <br />E <br />STILE <br />S <br />C <br />0 <br />R <br />E <br />TPN -G <br />Distance to Well from Tank <br />TPX-D <br />PKb,/EDB <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />Type of faiLure/discharge <br />>100 <br />catastrophic <br />51-100 <br />Long-term Leakage <br />Ioverfill <br />Fractures in subsurface (applies to foothills or mountain areas) <br />unknown <br />None <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received Yes <br />YES <br />No <br />Depth to Ground Water <br />DATE REFERRED <br />Ref/Year <br />DATE CLOSURE LETTER !AILED <br />Average Annual Precipitation <br />A= <br />14 <br />10-25 <br />On -Site Wells) <br />Yes <br />No <br />Number 8 Type <br />Irr <br />Doo <br />Pub <br />S <br />C <br />0 <br />R <br />E <br />Score <br />10 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />9 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />5 pts <br />if <br />condition <br />is met <br />Distance to Well from Tank <br />ft; ft; ft <br />V. Site Feature - Leaching Potential Analysis <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />51-100 <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) <br />xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water we(ls, ponds) <br />None <br />Unknown <br />Present <br />Unique site features: Recharge area, coarse soil, nearby wells.At <br />xxxxxx <br />None <br />least <br />one <br />More than <br />one <br />COLUMN TOTALS>»TOTAL POINTS <br />* <br />+ <br />_ <br />Sample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />41 - 48 pts <br />40 pts or Less <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />8 <br />1 <br />T <br />50 <br />X <br />50 <br />E <br />50 <br />8 <br />.3 <br />T <br />.3 <br />X <br />1. <br />E <br />1. <br />MA\3 <br />Samp(e Result: <br />TPH <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />GASOLINE <br />1000 <br />100 <br />10 <br />DIESEL <br />10,000 <br />1000 <br />100 <br />FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the Leaching potential <br />analysis. (i.e., site is currently an UGT Contamination List for soil or grand 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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />V1. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX 8 E or TPN Concentrations > Allowable Levels "Yes No <br />2. Recommend Site Closure Yes No 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 <br />YES <br />NO <br />REFERRED TO SITE MITIGATION FOR EVALOATION YESI NO <br />DATE REFERRED <br />/ / <br />DATE CLOSURE LETTER !AILED <br />NAME OF <br />EVALUATOR <br />EN 23 80 (UGTWKSHT)\5/90 <br />