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SAN JOAQUIN r':,_t4TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL Hr\iT*4 7IVISION <br /> I ST WORKSHEET FOR SITE CLOSURE EVALUATION DATE �/ r �► <br /> NAME Of FACILITY ��►�il� �� !SHEEPS CODE 7 <br /> OF <br /> rG7 /, TANK ID ' <br /> 3; <br /> TANK SIZE <br /> IZK.rnhFUEL TYPE <br /> is <br /> it, GENERAL SITE HISTORY !; <br /> f � <br /> Is permit current? Yes No Permit - Facility Status Code O Dac.Soit/GVH Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available} ✓jL Type of Tank Steel IFbrgl Sngl Dual <br /> 1 III. TANK HISTORY <br /> Was Tank tested? Yes Ha Failed precision test ? Yes Na If yes, give date(s) <br /> Was a repair made to the rank system! Yes No If yes, what was repaired?I <br /> I Was repair done under inspection? Yes No{ (Were soil samptes analyzed? Yes No BTX( TPM-G TPH-0 IPb/EDB <br /> 1_ I <br /> Type of faiture/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 b� No Depth to Ground eater j � Ref/Year �6 IQj Average Annual Precipitation A= 14 10-25 <br /> On-Site WeEI( Irr Dom Pub ii <br /> i <br /> S Score S Score S Scare <br /> Distance to WetL(s) from Tank ^ Iy L ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if D 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 /> i Minimum Depth to groundwater from the Soil Sample (feet) Zo I ,L>100 I I51-100 I O 25-50\1 <br /> ! Fractures in subsurface (applies to foothills Or mountain areas) (mane I Unknown I Present <br /> Average Annual Precipitation (inches) IXXXXXXJIa<10 I 9 10-25 Ixxxxxxxi 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) Unknown S Present <br /> Unique site features: Recharge area, coarse sail, nearby welLs. f At least More than <br /> xxxxxxj!iNone one one <br /> COLUMN TOTALS»>TOTAL POINTS + I?' r + <br /> € Ik <br /> Sample Result: CB T X OR E) RANGE OF TOTAL POINTS 49 pts or more' 41 - 48 pts 0 pts Or less <br /> - H.'D 8 Ix E aTT <br /> X EMAXIMUM ALLOWABLE ii-T-X-E LEVELS (PPM) 1 50 50 50' .33 1. t. 9A\3 <br /> Sample Resul :. GASOLINE lona I 100 10 <br /> Samt <br /> m p. esuL ci ►��`CT MAXIMUM ALLOWABLE TPH LEVELS (PPM) DEESEt 10,000 1000 100 <br /> a �nTo�l _1 TPH-_D <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, d0 not complete the leaching potentia( <br /> analysis. (i.e., site is currently On UGT Contamination List for soil or ground water.) <br /> i \1 If depth is > 5 ft. and < 25 ft., score 0 points. if depthl<=5 ft'., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. ;i <br /> \3 Levels for BTXXE are not applicable at a TPH concentration of 10 ppm (gasoline) or 1110 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION S/ �S .5; GY' <br /> 1. Are BTX $ E ar' TPH Concentrations > Allowable Levels *Yes Ho <br /> 2. Recommend Site Closure Yes Na If Yes, Refer to Site Nitigation,�for Evaluation <br /> i <br /> VII. REVIEW EVALUATION - TO 8E COMPLETED 6Y A SUPERVISOR/SENIOR P <br /> ' CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES{ NOI REFERRED TO SITE MITIGATION FOR EVALUATIONIY£SNO <br /> i w <br /> DATE REFERRED / / IDATE CLOSURE LETTER MAILED A / / <br /> i NAME OF <br /> EVALUATOR ' <br /> EH 23 80 (UGTWKSHT)\5/90 �� <br />