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SAN JOAOUIN',"4TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HFI, 'DIVISION f <br /> I r ;T WORKSHEET FOR SITE CLOSURE EVALUATIOI' <br /> g <br /> OF FACILITY DATESWEEPS CODE <br /> SS -55 ) e ,.lei <j TANK ID #SIZE /FijGe%F_ FUEL TYPE 0i�/� <br /> II. GENERAL SITE HISTORY f <br /> Is permit current? Yes No Permit # <br /> Facility Status Code OOc.Soil/GW Cont Yes No <br /> Number of Tanks at facility Age Of Tanks(if available). <br /> TyII pe of Tank Steel Fbrg! Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes <br /> No If yes, give date(s) / <br /> Was a repair made to the tank system? Yes No [f yes,, chat was repaired <br /> Was repair done under inspection? Yes NO Were soil samples analyzed? Yes No BTXE TPH-G TPH-D p6/EDB <br /> Type of failure/di'scharge - catastrophic long-term Leakage orerfill 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 <br /> ��: Average Annual Precipitation A= 14 10-25 <br /> Om Site Wel L(s) Yes No Number 8 -Type Irr Dom Pub <br /> Distance to WeLL(S) from Tank - S Score S Score S Score <br /> ft; ft; ft C 10 pts C 9 pts C 5is <br /> if <br /> 0 if 0 if 0 P <br /> V. Site Feature - Leaching Potential Analysis R condition R condition R condition <br /> E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Samp a (feet) S >100 <br /> :. 51-100 - 25-SOV <br /> Fractures in subsurface (applies to foothills or mountain areas) q <br /> -. None 1 UnknownPresent <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 <br /> 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None <br /> Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. <br /> At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + ',Z <br /> Samplesul.[: (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 B T X E <br /> mq MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 <br /> Se (2e <br /> a,pLvA� �(f1�- GASOLINE 1000 100 I <br /> hl I J' MAXIMUM ALLOWABLE TPH LEVELS (PPM) 10 <br /> - -� TPH� DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is <br /> PE: enh-- +aet� to the leaching potential <br /> analysis, (i.e., site is currently on UGT"-ontaminatian List for soil or gro ater.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points If depth r_5 ft,,. do -not use table. <br /> \2 If precipitation is > 40 inches, score 0 points.----- <br /> I \3 Levels for STXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel), - <br /> .. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No *If Yes, Refer to Vte Mitigation for Evaluation <br /> I. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES 0 <br /> DATE REFERRED / / '�/� DATE CLOSUFIE LETTER MAILED <br /> NAME OF G <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> a <br />