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SAN JOAQUIN CPUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA�IVISION <br /> I. WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME Of FACILITY 7 _ � (SLJE=PS CODE <br /> ADDRESS ` 3 E- , TANK tD � ; - '2 <br /> TANK SIZE ©D FUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit - (Facility Status Code Doc.SaiL/GW Cant Yes No <br /> Number of Tanks at facility Age of Tanks(if available)( Type of ranklSteel Fbrgl Sngt Ouat <br /> III. TANK HISTORY <br /> Was Tank tested?IYes Nol failed precision test ?IYes No If yes, give dates) <br /> [Was a repair made to the tank system? Yes NoI If yes, what was repaired?I <br /> Was repair done under inspection?IYes, No+ Were soil samples analyzed? Yes No STXE) TPH-G) TPH-O 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 IYes l No (Depth to Ground Water Ref/Year) (Average Annual Precipitation lA= 14 10-25 <br /> l l I <br /> On-Site Wetl(s) Yesl No Number & Type IIrr Dom iPubl <br /> S Score S Score 5 Score <br /> Distance to WeLL(S) from Tankl ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if O if <br /> R condition R condition R condition <br /> IV. Site Feature - Leaching Potential Analysis -c is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) , I >1DO I I51-100 ` 125-50\1 <br /> Fractures in subsurface (appties to foothiLLs or mountain areas) None I Unknown (Present <br /> 'Average Annual Precipitation (inches) xxxxxxl <10 I 9 10-25 Ixxxxxxx 26-40\2 <br /> ,Man-Made conduits which increase vertical migration <br /> iof leachate (i.e., septic systems, water weLLs, ponds) I None I Unknown I (Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. I At Least) More than <br /> lxxxxxxl None ` one one <br /> COLUMN TOTALS»>TOTAL POINTS I + I I + I = <br /> Sample 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 B-T-X-E LEVELS (PPM) 11 50I 50� 50 I .3 J. <br /> 11. 1. I 9A\3 <br /> iSampte Result;. GASOLINE <br /> TPH 1000 l 100 ( 10 <br /> i MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> DIESEL 10,000 1000 I 100 <br /> FOOTNOTES: * T f documented sail and/or ground water contamination is present, do not complete the Leaching potential <br /> analysis_ (i.e., site is currentty 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 Levets for BTX&E are not applicable at a TPH concentration of 10 ppm (gaso(ine) or 100 ppm (dieset). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levets *Yes) No <br /> 2. Recommend Site CtosureIYes l 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 CLOSURE�YESI NOI REFERRED TO SITE MITIGATION FOR EVALUATIONIYESI INOI <br /> DATE REFERREDI / / IDATE CLOSURE LETTER MAILED( <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />