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SAN JOAOUIN STY PUBLIC HEALTH S-cRVIC`S/ENVIRONMENTAL 40 <br /> DIVISION <br /> I. ST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY C_tCt r- SWEEPS CODE <br /> (ADDRESS 30 35C� ��UL+ TANK ID ;*I <br /> C)� <br /> TANK SIZE (G,UUU (FUEL TYPE 'l�,C" C04 �J <br /> ,!TANK <br /> SITE HISTORY <br /> Is permit current? Yes IN Permit - Facility Status Cade IDoc.Soil/GW Cant Yes Hal <br /> Number of Tanks at facility+ Age of Tanks(if available) (,fin k (Type of TanklSteell\'/IFbrgl Isngl � Ouat <br /> 111. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes' Nol _'-11f yes, give date(s)I <br /> Was a repair made to the tank system? Yes No F17 IIf yes, what was repaired?I <br /> Was repair done under inspection?iYes No Were soil samples analyzed? Yes --- No BTXE TPH-GI TPH-DIi/IPb/ <br /> 1 EDB( <br /> Type of failure/discharge catastrophic long-term leakage overfill) )unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground WateriIRef/Yearqq s ; Average Annuat Precipitation A= 14 i10-25 <br /> On-Site Well(s)IYes No (Number & Type Irr Doml Pubs <br /> S Scare S Scare S Score <br /> Distance to Wetl(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if O if O if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is meta is met E is met <br /> (t Minimum Depth to groundwater from the Soil Sample (feet) i >100 C�` I5t-100 I 125-5D\i <br /> (Fractures in subsurface (applies to foothills or mountain areas) i None i I Unknown I (Present <br /> (Average Annual Precipitation (inches) Ixxxxxxl (10 I 9 110-25 Ixxxxxxxl 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water welts, ponds) I I None I Unknown I (Present <br /> Unique site features: Recharge area, coarse sail, nearby wells. I=xx= I At least) More than <br /> I None one one <br /> COLUMN TOTALS>>>TOTAL POINTS I i - I <br /> ' I= '33 7 <br /> Sample Result: (3 T X OR E) RANGE Of TOTAL POINTS 49 pts or more 41 - 48 pts i 40 pts or Less <br /> MAXIMUMALLOWABLE B-T-X-E LEVELS (PPM) 1 50I 50I 50 I .3 I.3 I <br /> 1.I t. I NA\3 <br /> SampleMtt:_ rte;» GASOLINE 1000 t00 I10 <br /> j/��j MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH®. DIESEL 10,000 I 1000 I 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 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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (dieset). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations ) Allowabte Levels *Yesl )< .,jo _ 7 <br /> 2. Recommend Site Closure,Yes) Na x I If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO SE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREiYESI NCI REFERRED TO SITE MITIGATION FOR EVALUATIONIYESi IN <br /> DATE REFERRED( / / IDATE CLOSURE LETTER MAILEDI <br /> NAME OF <br /> EVALUATOR <br /> EN 23 80 (UGTWKSHT)\5/90 <br />