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SAN JOAQUIN Cr UBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL'ftISION <br /> "% , T WORKSHEET FOR SITE CLOSURE EVALUATION N40011DATE Y17 <br /> L <br /> - SWEEPSCODE �3�1� / TANK ID # 471DFUEL TYPE O <br /> II. GENERAL SITE HIStAY .** <br /> Is permit current? Yes No Permit # - Facility Status Codel 017100 Cant1yesl Imo <br /> Number of Tanks at facility Age of Tanks( available) /yy�'J� Type of Tank Steel Fbrgl Sngl Oual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No If yes, give dates) ,s7 /j j/7'X, <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? VVV� ery <br /> Was repair done under inspection? Yes NojW:e::soi1 samples analyzed? Yes No BTXE TPN-G TPN-0 Pb/EDB <br /> Type of failure/discharge catastrophic l -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 Water Ref/Year Average Annual Precipitation A= 14 10-25 <br /> on-Site WeLL(s) Yes No Number & Type Irr Dom Pub 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 /> Minimun Depth to groundwater from the Soil Sample (feet) 50—I D >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 xxx:o= 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 ane one <br /> COLUMN TOTALS»TOTAL POINTS I o * 12 * / 0 _39 <br /> Samote Result• B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 is or less <br /> <TK�7� D <br /> B T X I EB T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result- ` GASOLINE 1000 100 10 <br /> ?-K a - i 40 O IMUM ALLOWABLE TPH LEVELS (PPM) <br /> b4oPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the i <br /> analysis. (i.e., site is currently an 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 BTXSE are not applicable at a TPH concentration of 10 ppm► (gasoline) or 100 ppm (diesel). �- <br /> VI. STAFF RECOMMENDATION/CONCLUSION S /a� � • /� <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels *Yes No �• �� � <br /> 2. Recommend Site Closure Yes No if Yes, Refer to Site Mitigation for Evaluation C � <br /> VII. REVIEW EVALUATION - To BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMMENDATION FOR CLOSURE YES L NO REFERRED To SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />