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SAN JOAQUIN C 'USLIC HEALTH SERVICES/ENVIRONMENTAL HEALT' VISION <br /> I• I W WORKSHEET FOR SITE CLOSURE EVALUATION r <br /> NAME OF FACILITY /S 14'U-7L0 SWEEPS CODE TANK ID <br /> ADDRESS 3 C7 v S /C # <br /> C 3/ - lvj� - otos <br /> TANK SIZE FUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit # - Facility Status Code j Z Doc oil Cont Yes o <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel brgl I Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 1 Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPH-01 I <br /> Pb/EDB <br /> Type of failure/discharge catastrophic tong-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 Water35 Ref/Year Q�; Average Annual Precipitation A= 14 10-25 <br /> On-Site Wells) Yes No Number & Type Irr Dam Pub <br /> S Score S Score S Score <br /> Distance to Well(s) from Tank ft; 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 /> Minimum Depth to groundwater from the Soil Sample (feet) �� >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxx 26-40\2 <br /> 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 C) + _36 �+ s - L{ <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more / 41 - 48 p 40 pts or less <br /> 31 T X E/ B JT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 5Q .3 .3 1.I 1. NA\3 <br /> Sade 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 r eta the leaching potential <br /> analysis. (i.e., site is currently on UGT contamination List for soil 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 RECOMMENDATION/CONCLUSION <br /> �c J 1���� li � <br /> 1. Are BTX & E or TPH Concentrations > Allow a Levels *Yes No O 'pY' �� ��p� iC�D �ro <br /> 2. Recommend Site Closure Yes No � *If Yes, Refer to Site Mitigation for Evaluation C Y <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECO MENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YE 01 1 <br /> DATE REFERRED /G / �7� DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 30 (UGTWKSHT)\5/90 <br />