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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> JaST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY <br /> a, jn SWEEPS CODE <br /> ADDRESS e <br /> -/ c TANK ID '� 'Z/ - / _ 0 <br /> TANK SIZE � FUEL TYPE L � l` <br /> II. GENERAL SITE HISTORY <br /> TNe, <br /> t current+ Yes No ermit R Facility Status Code Doc.Soil/GW Cont Yesf Tanks at facility '3 Age of Tanks(if available) G Type of Tank Steel Fbrgl Sngl Dual <br /> [If. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 Yes No If yes, give date(s) <br /> was a repair made to the tank system? Yes No f yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil saeples analyzed? Yes No BTXE TPH-G TPN•D 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 Ref/Year Average Annual Precipitation A= 14 10-25 <br /> On-Site weLL(s) Yes No Nunber 8 Type Irr Puh <br /> Distance to Wells) from Tanktt; ft. S Score S Score S Score <br /> ft C 10 pis C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> V. Site Feature . Leaching Potential Anal R condition R condition R condition <br /> Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 <br /> 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown <br /> Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx <br /> 26-40\2 <br /> j Man-Made conduits which increase vertical migration <br /> of 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 one one <br /> COLUMN TOTALS»)TOTAL POINTS + <br /> Sale Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> B T X E BT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50i 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: a GASOLINE 1000 100 <br /> y3 MAXIMUM ALLOWABLE TPN LEVELS (PPM) 10 <br /> q G TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: —If documented soil and/or ground water contamination is present, do not complete the Leaching potential <br /> analysis. 0.e., site is currently on UGT Contamination List for soit 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 STXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels 'Yes '><' No <br /> 2. Recommend Site Closure Yesl 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 CL SURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CL SURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />