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SAN JOAQUIN ( Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL ?IVISION <br /> 1, ­3T WORKSHEET FOR SITE CLOSURE EVALUATICN DATE _ <br /> NAME OF FACILITY S f SWEEPS CODEI 3/7 0 41- <br /> ADDRESS �� TANK ID # <br /> TANK SIZE ' FUEL TYPE Jej�%j ? <br /> It. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit #11 Facility Status Code Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ?1Yes Natvr If yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes Nol BTXE ITPH-G TPH-0 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 Yes No Depth to Ground Water G Ref/Year Average Annual Precipitation A= 14 10-25 <br /> On-site Wells) Yes No Number & Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to Wells) from Tank ft; ft; ft C 10 pts_ C 9 pts C 5 pts <br /> O 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 /> Minimum Depth to groundwater from the Sail Sample (feet)5U--� s >100 1 151-100 125-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) Norse I Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 1 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) I None a I Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxXxx None ane '�j/one <br /> COLUMN TOTALS»>TOTAL POINTS J * 4f <br /> Sample Resuit• (B 7 X OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 - 48 pts 40 pts or Less <br /> B T XE B X EMAXIMUM ALLOWABLE: B-T-X-E LEVELS (PPM) 1 50 50 50 .3 IT <br /> .3 1.I 1. NA\3 <br /> Sample Result- GASOLINE 1000 100 I 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: "*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 sail or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth 4 <br /> =5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for 3TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No If Yes, Refer to site Mitigation for Eva luation `���--t ' a—�7'"(✓� <br /> VII. REVIEW EVALUATION - TO RE COMPLETED SY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YESI INC 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 />