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SAN JOAQUINY PUBLIC HEALTH SERVICES/ENVIRONMENTAL I VISION <br />1. OT WORKSHEET FOR SITE CLOSURE EVALUATION!DATE 47c/ <br />NAME OF FACILITY I_ (SWEEPS CODE <br />ADDRESS!)iTANK ID <br />TANK SIZE (FUEL TYPE <br />II. GENERAL SITE HISTORY <br />Is permit current? IYes No <br />Permit *I <br />- Facility Status Code r IDOC.SoiL/GW ContjYesXj <br />I I <br />(Number of Tanks at facility <br />No <br />(Age of <br />Tanks(if availatle) <br />Type of Tank ISteel IFbrgl ISngl <br />Duall <br />III. TANK HISTORY <br />Was Tank tested? Yes No <br />No <br />Failed precision test ?IYes <br />No IIf yes, give date(s)I <br />Was a repair made to the tank syste;IYes <br />No <br />If yes, what <br />was repaired?( <br />Was repair done under inspection? Yes <br />NoI Were soil sample: <br />analyzed? I Yes I INo <br />BTXEI ITPH-GI TPH-D <br />Pb/EDB( <br />Type of failure/discharge' <br />catastrophic <br />hong-term leakagel <br />overfill unknown other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLL:CT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples ReceivedLYesl <br />No <br />Depth to Ground Water <br />IRe /Year Average I g Annual Precipitation <br />A= 14 10-25 <br />On -Site Well(s)IYes INo Number & Type <br />IIrr <br />Dom <br />ubI <br />S <br />C <br />Scare <br />10 pts <br />S <br />C <br />Scare <br />9 pts <br />S <br />C <br />Score <br />5 pts <br />Distance to WeiL(s) from Tank ft; ft; f <br />0 <br />R <br />if <br />condition <br />0 <br />R <br />if <br />condition <br />0 <br />R <br />if <br />condition <br />V. Site Feature - Leaching Potential Analysis <br />E <br />is met <br />E <br />is met <br />E <br />is met <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />I >100 <br />I <br />51-100 <br />I <br />125-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />I None <br />I <br />I Unknown <br />Present <br />Average Annual Precipitation (inches) <br />Ixxxxxxl <br /><10 <br />I 9 <br />110-25 <br />Ixxxxxxx <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water wells, ponds) <br />None <br />` <br />Unknown <br />Present <br />site features: Recharge area, coarse soil, nearby wells.` <br />At least) <br />More than <br />(Unique <br />xxxxxxlj <br />None <br />one <br />one <br />COLUMN TOTALS> >TOTAL POINTS <br />+ <br />I <br />( + <br />Sample Result: (B T X OR E) RANGE OF TOTAL DINTS 49 pts or more 41 - 48 pts 40 pts or Less <br />B T X -c 4 X EMAXIMUM <br />.3 1.M 1. INA\3 <br />ALLOWABLE B -T -X -E LEVELS (PPM) 1� 50, 50� 50 .3 JT <br />Sample Result: GA DLINE 1000 100 10 <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />TPH 01 SEL 10,000 I 1000 I 100 <br />FOOTNOTES: *"If documented soil and/or ground water conta ination is present, do not complete the leaching potential <br />analysis. (i.e., site is currently on JGT Contamination List for soil or ground water.) <br />\1 If depth is > 5 ft. and < 25 ft., score 0 po nts. If depth <=5 ft., do not use table. <br />\2 If precipitation is > 40 inches, score 0 poi ts. <br />\3 Levels for BTX&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 INo *If Yes, Refer to S to Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR r LD -P <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES( INOI (REF RRED TO SITE MITIGATION FOR EVA6jjiTION1YESj I NO <br />DATE REFERRED / / DATE CLOSURE LETTE MAILED / 1 <br />NAME OF <br />EVALUATORI <br />EH 23 80 (UGTWKSHT)\5/90 <br />