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SAN JOAOUIN C f PUBLIC HEALTH SERVIC'cS/ENVIROMMENTAL HEA TIVISICN <br /> I, '4T WORKSHEET FOR SITE CLOSURE c/ALUATION OATE1 7 <br /> ,NAME OF FACILITY L SWEEPS CCOE <br /> I '-�3 i5l <br /> 1ADORESS1 i 14 ,L R4, C p'A� ITANK IO AL -Is-/ ( _ <br /> (TANK SIZEI / � (FUEL TYPE 6A,So <br /> II. GENERAL SITE HISTORY <br /> FIs permit current?IYes( Nol Permit d - (Facility Status Code d.9 (Dec.So l/GW Cant Yes) No <br /> 4umoer of Tanks at facility) Age of Tanks(if available)( j ]Type of rwkl Steell Fbrgl Sngll OuaL <br /> ,.,. TANK HISTORY <br /> was Tank tested7l Yes ixiNo1 failed precision test ?IYes INoI if yes, give dace(s) <br /> ,.as a repair made to the tank systemY?lyes Not If yes, what was repaired?( <br /> '.':as repair done under inspection?1Yesl INoI IWere soil saaokes analyzes?IYes) INoI BTXEI ITPH-GI TPH-01 lPb/ED81 <br /> -ype of failure/discharge) I catastrophic I hong-tem Leakage Ioverfill I Iunk=anI )other: <br /> iV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE 0ETAILS/CCLLEC7 DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Sail Samples Received Yesl Not Depth to Ground Water) (Ref/Pearl (Average Annual Precipitation)A=114 110-251 <br /> 1Cn-ii ie 'JeLL(s)IYesl Nal (Number & Type trrl Dom lPuol <br /> S Score S Score S Score <br /> !Distance :o WeIL(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> O if O if O if <br /> 3 aanditian .R ecndition R condition <br /> IV. site Feature - Leaching Potential Analysis c is met E is met - is met <br /> 1 Minimum Depth to groundwater from the Soil Savile (feet) I I >100 I 151-100 25-50\1 <br /> 1F^oczures in suosurace (applies to foothills or mountain areas) ( None I I Unknown (Present <br /> !Average Annual Precipitation (inches) Ixxxxxxl <)0 l 9 l 10-25 =x xx) 26-4-aN2 <br /> .Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic system, wtw wel Ls, ponds) None I Unknown i Present <br /> Unique site features: Recharge area, coarse soil, nearby welts. At least) More then <br /> xxxxxxl Hone one one <br /> MT6E ,- n)VCOLUMN T TALS>»TOTAL POINTS <br /> B,mdLe ResuLL: (8 T X OR ?) RANGE OF TOTAL POINTS 49 pts or mor. I to - /$ pts 40 pcs or less <br /> .SS 1 A-e3 l) D Ss3= <br /> z I ( 3 .T Xi1 So 3 t. _ <br /> . NA\3 3r <br /> $SA AY' Q N D Wil'" \ xIMAALLOWABLE 3-T-X-E LEVELS (PPM) <br /> Sample <br /> p e�Result:J ALL <br /> M <br /> GASOLINE 1000 i 100 10 <br /> AXIMIALLOWABLE TPH LEVELS (PPM) <br /> DIESEL 10,000 l 1000 tOD <br /> FOOTNOTES: —If documented soil and/or ground nater awramineticn is present, do net complete the Leeching potential <br /> analysis. (i.e., size is currently on UGT Contamination List for soil or ground water.) <br /> \1 If dearth is > 5 ft. and < 25 ft., score 0 points. If depth c5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for STKEE are not applicable at a TPN concentration of TOppmppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOVMENOATION/CCNCLUSICM 5— / ' b 2i bi � <br /> l1. Are SIX 8 E or TPH Concentnatians > ALLowole Levels -Yes1 INoI Cts/& q���� � <br /> Z. Recommend Size Closure Yesl INe1 I If Yes, Refer to Site Mitigation for EVULuation W�S <br /> VII. REVIEW EVALUATION - TO 3E COMPLETED BY A SUPERVISOR/SEMIGR <br /> CrNWR WITH STAFF RECOMMENDATION FOR CLOSUREIYESI INoI IREFERRED TO SITE 91TIGATICH FOR ---VALUATION IYESI INoI <br /> GATE REFERRED IDATE CLOSURE LETTER .MAILED( <br /> NAME OF <br /> EVALUATORI <br /> EH 23 BO (UGTWKSHT)\5/90 <br />