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SAN JOAQUIN G f PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL )!VISION <br />1. 110ST WORKSHEET FOR SITE CLOSURE EVALUATION DATE — <br />NAME OF FACILITY SWEEPS CODE 3 <br />ADDRESS TANK ID *I- <br />i <br />TANK SIZE Q FUEL TYPE Z4,Q. e c� <br />11. GENERAL SITE HISTORY <br />e� <br />permit current? Yes No Permit # - Facility Status Code Doc.SoiL/GW Cont Yes No <br />fiber of Tanks at facility /C Age of Tanks(if available) l kf- Type of Tank Steel lyFbrgl SngL Dual <br />III. TANK HISTORY <br />Was Tank tested? <br />Yes <br />VN01 <br />No <br />failed precision test ? <br />Yes <br />L <br />No <br />If <br />yes, give date(s) <br />14 10-25 <br />Was a repair made to the tank system? Yes <br />No <br />If yes, what was repaired? <br />Ho )e.S LouWas <br />repair repair done under inspection? Yes <br />No <br />Irr <br />Were soil samples analyzed? <br />Yes <br />No <br />BTXE <br />Score <br />10 pis <br />if <br />condition <br />is met <br />TPH-G <br />Score <br />9 pts <br />if <br />condition <br />is met <br />TPH- <br />Score <br />5 pts <br />if <br />condition <br />is met <br />Distance to WeLI(s) from Tank <br />ft; ft; ft <br />Type of failure/discharge <br />V. Site Feature - Leaching Potential Analysis <br />catastrophic <br />long-term leakgeF <br />I <br />overfilL <br />unknown <br />I <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received Yes <br />No <br />Depth to Ground Water <br />Ref/Year <br />Average Annual Precipitation <br />A= <br />14 10-25 <br />On -Site WeLL(s) <br />Yes <br />No <br />Number 8 Type <br />Irr <br />Dam <br />Pub <br />S <br />C <br />0 <br />R <br />E <br />Score <br />10 pis <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 />5 <br />C <br />0 <br />R <br />E <br />Score <br />5 pts <br />if <br />condition <br />is met <br />Distance to WeLI(s) 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 />I <br />51-100 <br />25-50\1 <br />Fractures in subsurface (applies to foothiLLS or mountain areas) <br />None <br />I 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 welts. <br />At Least <br />one <br />More than <br />one <br />COLUMN TOTALS>>>TOTAL POINTS <br />t�None <br />f <br />= <br />Sampte 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 8 -T•% -E LEVELS (PPM) <br />B T <br />1 501 <br />X <br />50 <br />E <br />50 <br />B <br />.3 <br />T X <br />.3 1 1 1. <br />E <br />1. <br />NA\3 <br />Sample Result: <br />TPH <br />MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br />GASOLINE <br />1000 <br />100 <br />10 <br />DIESEL <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 8TX 8 E or TPH Concentrations > ALlowabLe Levels -Yes No <br />2. Recommend Site Closure Yes No •If Yes, Refer to Site Mitigation for Evaluation <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YESI NO REFERRED TO SITE MITIGATION FOR EVALOATION YES NO <br />DATE REFERRED / / DATE CLOSURE LETTER MAILED <br />NAME OF <br />EVALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />