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SAN JOAQUIN C PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL [VISION <br /> u T WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> FACILITYC;q �L SWEcPS CODE) _3 <br /> II <br /> ,ESS J^ t TANK ID 91 ) <br /> J 'E� <br /> ,ANK SIZE FUEL TYPE( <br /> fI. GENERAL SITE HISTORY <br /> Is Permit current? Yes No Permit r= <br /> Facility Status Code [)l Dae.Soii/GW Cant Yes I No <br /> Numoer of Tanks at facility. Age of Tanks(if avai(abLe)j_q_3. I Type of Tank ISteel Fbrgll Sngl Dual <br /> t'= cr <br /> III. TANK HISTORY <br /> Was Tank tested? Yes Na Failed precision test 7I Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yesl No if yes, what was repaired?( <br /> Was repair done under inspection? Yes !NPI Were soil samples analyzes?!Yes NolBTXEI (TPH-G TPH-D Pb/ED8 <br /> I ! i <br /> Type of failure/discharge) catastrophic) long-term leakage) overfillunknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes NoI Depth to Ground Water �()Ref/Year �/ Average Annual Precipitation A= 14 I10-25 <br /> On-Site We{l(s) Yes No Number & Type Irr Dom Pub! <br /> S Score S Score S $care <br /> Distance to We{l(s) from Tank ft; ft; <br /> It C 10 pts C 9 pts C 5 pts <br /> O if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis = is met E is met E is met <br /> (Minimum Depth to groundwater from the Soil Sample (feet) >100 X51-100 25-50\1 <br /> Fractures in sucsurface (applies to foothills or mountain areas) [ J I None Unknown_ Present <br /> ll � <br /> Average Annua{ Precipitation (inches) Ixxxxxxl <10 9 10-25 xxxxxxx 25-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachare (i.e_, septic systems, water walls, Ponds) More Unknown Present <br /> i <br /> Unique site features: Recharge area, coarse soil, nearby welts. At least More than <br /> xxxx:cx I Nona one one <br /> COLUMN TOTALS>»TOTAL POINTS I * * �_ <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 - 4$ pts 40 pts or less <br /> MAXIMUM ALLOWABLE 3-7-X-E LEVELS (PPM) 1 50I 50� 50 .3 .3 11. 1. � NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM 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 camp(are the leaching potential <br /> analysis. (i.e., site is currently an UGT Contamination List for sail 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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECCMMENDATION/CONCLUSION <br /> 1. Are 3TX & E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yesl No *if Yes, Refer to Site Mitigation for _valuation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYES� NOI IREFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED( / / DATE CLOSURE LETTER MAILS <br /> NAME OF I <br /> EVALUATOR, <br /> EH 23 80 (UGTWK5HT)\5/90 <br />