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1. <br />NAME OF FACILITY <br />SAN JOAQUIN C 'Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA' <br />laST WORKSHEET FOR SITE CLOSURE EVALUATION ..DIVISION� <br />DATE S- / <br />lJ' SWEEPS CODE( <br />ADDRESS "� E. <br />y h <br />c.� Q.� s TANK <br />TANK SIZE /D)Adyo FUEL TYPE /_)1 <br />11. GENERAL SITE HISTORY <br />Is permit current? Yes No <br />Facility Status Code Doc.Soi l/C4 Cont Yes No <br />Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br />1i1. LANK HISTORY <br />Was Tank tested? Yes No Failed precision test ? Yes INo if <br />yes, give dates) <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 TFG 17TPH -D Pb/ED8 <br />Type of failure/discharge catastrophic long-term leakage Ioverfill unknown other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received Yesi <br />YES <br />No <br />Depth to Ground Water <br />Ref/Year <br />INO <br />Average Annual Precipitation <br />A= <br />14 <br />10-25 <br />On -Site Wel L(s) <br />Yes <br />NAME OF <br />No <br />Number 8 Type <br />lrr <br />(Dan <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 frau Tank <br />ft; ft; £t <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 wells, ponds) <br />None <br />Unknown <br />Present <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />xxxxxx <br />None <br />At 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 pis or more <br />41 - 48 pts <br />40 pts or Less <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />B <br />1 <br />T <br />50 <br />%E <br />50 <br />50 <br />B <br />.3 <br />T <br />.3 <br />X <br />1. <br />E <br />1. <br />MA\3 <br />Sample Result: <br />TPH <br />GASOLINE <br />MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br />DIESEL <br />1000 <br />100 <br />10 <br />10,000 <br />1000 <br />100 <br />FOOTNOTES: •••if documented sail 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., 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 />VI. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX 8 E or TPH Concentrations > Allowable Levels -Yes No <br />2. Recommend Site Closure Yes No •If Yes, Refer to Site Mitigation for Evaluati <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 <br />YES <br />INO <br />DATE REFERRED <br />/ / <br />DATE CLOSURE LETTER MAILED <br />NAME OF <br />EVALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />