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SAN JOAQUIN f fY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE/ DIVISION <br /> WORKSHEET FOR SITE CLOSURE EVALUATION DATE .. ., <br /> NAME OF FACILITY SWEEPS CODE <br /> ADDRESS31A-7 E, �"f TANK ID # <br /> TANK SIZE FUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> rrr <br /> Is permit current? Yes No Permit # - Facility Status Code117,71 Doc.SoiL/GW Cont Yes No <br /> Number of Tanks at facility (9— Age of Tanks(if avaiLabte)j&_,.0 Type of Tank Steel Fbrgl Sngl Dual Lj <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No I XFailed precision test ? Yes No If yes, give date(s) / <br /> Was a repair made to the tank systemf? Yes No I VIf yes, what was repaired? <br /> ;Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPH-D I Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water Ret/Year Average Annual Precipitation A=114 10-25 <br /> On-Site WeLL(s) Yes No Number & Type Irr Dam Pub <br /> S Score S Score S Score <br /> Distance to WeIL(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> O if O 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) D_. )100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) D None Unknown Present <br /> jAVerage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> ,Man-Made conduits which increase vertical migration <br /> hof leachate (i.e., septic systems, water wells, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None Cl1 one one <br /> ' <br /> COLUMN TOTALS> TOTAL POINTS I D - / 9' <br /> b <br /> - I D = 3 <br /> S�l' Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 4 pts or less <br /> //�� F/IV/D 8 T % E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> S le sue o� ./y� GASOLINE 1000 100 10 <br /> KI(QJ b�r O J4114UM ALLOWABLE TPH LEVELS (PPM) <br /> TPH � DIESEL 10,000 1000 100 <br /> FOOTNOTES: •••If documented soil and/or ground water contamination is present, do not complete the Leaching potentia <br /> analysis. (i.e., site is currently on UGT Contamination List for sail or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., scare 0 points. if depth <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION :pag' s �� 4` dJ -1•�3't{� I - ��Q f �A�J jyL <br /> lF <br /> 11. Are BTX & E or TPN Concentrations > Allowable Levels 'Yes NoI xi <br /> Sfoc f<2- Recommend Site closure Yes No If Yes, Refer to Site Mitigation for Evaluation) Ip/y ^ A0 7 LP f VK- <br /> V1 <br /> r I' JJ <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR T _ D. -f0 b,-- <br /> CONCUR <br /> ,--CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YEB NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO I kl <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED / / <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />