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SAN JOAQUIN CDUNBLIC HEALTH SERVICES/ENVIRONMENTAL HFALTHAM SION <br /> UG WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> ° SWEEPS CODE '� L <br /> NAME OF FACILITY <br /> i <br /> ADDRESS <br /> TANK SIZE J. FUEL TYPE 42� <<' <br /> 11. GENERAL SI E HISTORY m <br /> t current? YesNa <br /> FaciLity Status Code Doc.Soi L/GW Cont Yes No <br /> Is permiPermit # - <br /> ll <br /> Number of Tanks at facility + Age of Tanks(if available) DAX L.. (Type of Tank Steel Fbr9L SngL1 Dual <br /> Ill. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Ilwas repair done under inspection? Yes No Were soil samples anaLyzed? Yes No BTXE TPH-G TPH-13Pb/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 1.36 Ref/Year J o ; Average Annual Precipitation A= 14 10-25 <br /> On-Site WeLL(S) Yes No Number & Type 11 Tlrl I 1D.11 IPUbl <br /> S Score S Score S Scare <br /> Distance to WeLL(s) from Tank jjaLft; ^ �ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 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 /> 3� >100 I51-100 25-50\1 <br /> Minimum Depth to groundwater from the Soil Sample (feet) 6v�= <br /> Fractures in subsurface (applies to foothills or mountain areas) I I None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration None Unknown Present <br /> of leachate (i.e., septic systems, water wells, ponds) <br /> At least More than <br /> Unique site features: Recharge area, coarse Soil, nearby wells. XXXXXX None one one <br /> COLUMN TOTALS»>TOTAL POINTS I lJ ` I D Cl <br /> Sample Result: (S T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> /V D B T X E B T X E <br /> MAXIMUM ALLOWABLE S-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1 NA\3 <br /> 10 <br /> Sample Result: <br /> _ <br /> 1 PM D MAXIMUM ALLOWABLE TPH LEVELS (PPM) GASOLINE 1000 100 <br /> loll J�'I� TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: "'*If documented soil and/or ground water contamination is present, do not complete the l ching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground we <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. Pp" ppm (diesel). <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 (gasoline) or 100 <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels 'Yes No ���/ w <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 YESNO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> n <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />