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SAN JOAQUIN PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE DIVISION <br /> I. T WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY I °' / SWEEPS CODE <br /> �ADDRESSI O J (TANK ID <br /> TANK S17EJ Vo FUEL TYPE <br /> G <br /> II. GENERAL SITE HI ORY <br /> Is permit current? Yes INo (Permit - (Facility Status Code Doc.SoiL/GW Cont Yes NoI <br /> Number of Tanks at facility) Age of Tanks(if available)( (Type of Tank Steel Fbrgl ISngll Dual <br /> III. TANK HISTORY <br /> !Was Tank tested? Yes Nol failed precision test ?IYesl INo If yes, give date(s) <br /> Was a repair made to the tank systemm? Yes NoI If yes, what was repaired?I <br /> Was repair done under inspection? Yesl NoI Were soil samples analyzed? Yes No BTXEI TPH-GI ITPH-DI IPb/EDB <br /> i <br /> Type of failure/discharge (catastrophic) Long-term leakage (overfill Iunknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> jSoil Samples Received Yes No Depth to Ground Water) IRef/Year �� ; (Average Annual Precipitation lA=I14 10-25 <br /> ;On-site Wells) Yesl INo (Number & Typel IIrr Dan (Pun) <br /> S Score S Score S Score <br /> Distance to WeIL(S) from Tankl ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R conditian R condition <br /> V. Site Feature - Leaching Potential Analysis E is met c is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) I >100 I51-100 I 125-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) Ir I None Unknown I (Present <br /> (Average Annual Precipitation (inches) xxxxxxl <10 9 1 10-25 Ixxxxxxxl 26-40\2 <br /> (Man-Made conduits which increase vertical migration <br /> of Leachate (i.e., septic systems, water wells, ponds) I None I I Unknown i (Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. I I At least More than <br /> xxxxxx None I` one one <br /> i <br /> I COLUMN TOTALS>>>TOTAL POINTS ho I + la <br /> I + I 1= 39' <br /> Samole Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts I 40 pts or less <br /> MAXIMUM ALLOWABLE 3-T-X-E LEVELS (PAM) 1 50I 50 50 I .3 I.3 11.1 1. I 4A\3 <br /> isamole Result.-_* GASOLINE 1000 I 100 I 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 I 1000 I 100 <br /> IFOOTNOTES: *"If documented soil and/or ground water contamination is present, do not complete 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 < Z5 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 BTXB.E are not applicable at a TPH concentration of 10 ppm (gaso(ine) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLllSION <br /> i1. Are 3TX & E or TPH Concentrations > Allowable Levels *Yes) No <br /> 12. Recommend Site CtosurelYes I NoI if Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO 3E COMPLETED 3Y A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES INOI REFERRED TO SITE MITIGATION FOR EVALUATION I YES I NO) I <br /> DATE REFERRED( / / (DATE CLOSURE LETTER MAILS <br /> LEALUATCRI <br /> E OF <br /> EH 23 80 (UGTWKSHT)\5/90 <br />