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SAN JOAQUIN YPUBLIC HEALTH SERVICES/ENVIRONMENTAL HE DIVISION <br />I. T WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br />NAME OF FACILITY f'I SWEEPS CODE <br />ADDRESSffi S` - ��, 1TANK ID # 1/ —40 <br />TANK SIZE FUEL TYPE04 age I <br />C1 <br />s permit current? Yes No Permit # - Facility Status Code DOc.SOiL/GW Cant Yes No <br />umber of Tanks at facility Age of Tanks(if available) Type of Tank ISteel Fbrgl Sngl F Dual <br />III. TANK HISTORY <br />Was Tank tested? <br />Yes <br />No <br />NO <br />Failed precision test ? <br />Yes <br />No <br />Average Annual Precipitation <br />If yes, give date(s) <br />14 <br />Was a repair made to the tank system? <br />Yes <br />No <br />If yes, what was repaired? <br />No <br />Was repair done under inspection? Yes <br />No <br />Were soil samples analyzed? Yes <br />No <br />BTXE ITPH-G TPH-0 <br />Pb/EDB <br />Type of failure/discharge <br />catastrophic <br />long-term leakage <br />overfill <br />unknown <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received <br />Yes <br />No <br />NO <br />Depth to Ground Water <br />Ref/Year <br />Average Annual Precipitation <br />A= <br />14 <br />10-25 <br />On -Site WeLL(s) <br />Yes <br />No <br />Num& Type <br />Irr <br />Dom <br />L. <br />Pubber <br />S <br />Score <br />S <br />Score <br />S <br />Score <br />Distance to WeLL(S) from Tank ft; ft; ft <br />C <br />10 pts <br />C <br />9 pts <br />C <br />5 pts <br />0 <br />if <br />0 <br />if <br />0 <br />if <br />R <br />condition <br />R <br />condition <br />R <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 />51-100 <br />I <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />Present <br />Average Annual Precipitation (inches) <br />xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water wells, ponds) <br />I None <br />Unknown <br />Present <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />eA <br />At least <br />More than <br />xxxxxx <br />None <br />one <br />one <br />COLUMN TOTALS>»TOTAL POINTS <br />J <br />+ <br />1:2 <br />+ <br />Sample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />41 - 48 pts <br />40 pts or less <br />B <br />T <br />X <br />E <br />B <br />X <br />E <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />1 <br />50 <br />50 <br />50 <br />.3 <br />JT <br />.3 <br />1. <br />1. <br />NA13 <br />Sample Result: <br />GASOLINE <br />1000 <br />100 <br />10 <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />DIESEL <br />10,000 <br />1000 <br />100 <br />TPH <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 (diesel). <br />VI. STAFF RECOMMENDATION/CONCLUSION _ <br />1. Are BTX & E or TPN Concentrations > Allowable Levels *Yes No <br />* <br />2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE <br />YES NO REFERRED TO SITE MITIGATION FOR EVALUATION <br />YES <br />NO <br />DATE REFERREDi <br />DATE CLOSURE LETTER MAILED <br />NAME OF <br />EVALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />