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SAN JOAQUIH PUBLIC HEALTH SERVICES/ENVIRONMENTAL H DIVISION <br />I. T WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br />NAME OF FACILITY SWEEPS CODE J <br />ADDRESS` TANK ID ff ' ®` 7 <br />TANK SIZE FUEL TYPE <br />II. GENERAL SITE HISTORY <br />s permit current? Yes No Permit � - Facility Status Code Doc.Soil/GW Cont Yes No <br />snber of Tanks at facilityl Age of Tanks(if available)( (Type of Tank Steel Fbrgl Sngl Dual <br />TANK HISTORY vd`rjAt<p <br />Was Tank tested? Yes <br />No Failed precision test ? <br />Yes <br />No <br />If yes, give date(s) / / / / <br />Was a repair made to the tank system? Yes <br />NoI <br />If yes, what was repaired?I VC ` <br />Was repair done under inspection? Yes <br />No Were soil samples analyzed? Yes No <br />BTXE TPH-G <br />ITPH-D IPb/EDB <br />Type of failure/discharge (catastrophic <br />long-term leakage <br />S <br />C <br />0 <br />R <br />E <br />overfill <br />unknown <br />otifm <br />her: }P <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS)` <br />Soil Samples Received Yes <br />No Depth to Ground Water <br />50IRef/Year1949 (Average Annual Precipitation <br />A=114 <br />1 10-25 <br />On -Site Well(s)IYes ) No <br />INumber & Type <br />Irr <br />Dom <br />IPub <br />S <br />C <br />0 <br />R <br />c" <br />Score <br />10 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />9 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />5p is <br />if <br />condition <br />is met <br />(Distance to Wells) from Tank) ft; ft; ft <br />V. Site Feature - Leaching Potential Analysis <br />;Minimum Depth to groundwater from the Soil Sample (feet) <br />I >100 <br />I <br />I51-100 <br />I <br />125-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />Norte <br />I Unknown <br />I <br />(Present <br />(Average Annual Precipitation (inches) <br />xxxxxxl <br /><10 <br />I 9 <br />110-25 <br />Ixxxxxxxi <br />26-40\2 <br />IMan-Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water wells, ponds) <br />I None <br />I <br />Unknown <br />I (Present <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />xxxxxx <br />Norte <br />I <br />At least <br />one <br />More than <br />one <br />{ <br />COLUMN TOTALS>>>TOTAL POINTS <br />+ I <br />+ <br />Sample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />41 - 48 pts I <br />40 pts or less <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />31 <br />1 <br />T I <br />50 <br />X <br />50 <br />I ET <br />50 I <br />X <br />.B 3 i.3 11. <br />E <br />1_ I <br />NA\3 <br />Sample Result:. <br />TPH <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />GASOLINE <br />1000 I <br />100 I <br />10 <br />DIESEL <br />10,000 <br />1000 I <br />100 <br />FOOTNOTES: *"If documented soft and/or ground water contamination is present, do riot 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 TPH Concentrations > Allowable Levels *Yes No <br />2. Recommend Site Ctosure Yes INo If Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SEHIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYES NOI REFERRED TO SITE MITIGATION FOR EVALUATION I YESI INOI I <br />DATE REFERRED+ IDATE CLOSURE LETTER MAILED( <br />NAME OF <br />EVALUATOR <br />EN 23 80 (UGTWKSHT)\5/90 <br />