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SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I• WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY . <br /> EPS CODE <br /> ADDRESS TANK ID 9 - <br /> TANK SIZE FUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> *** <br /> Is permit currant? Yes No Permit # facility Status Coda Doc.SOit/moi Cant Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgt SrQ Oval <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No 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 L <br /> No Were salt suptes analyzed? Yes No BTXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic tong-term leakage overfill junknowni lather: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Sail Samples Received Yes No Depth to Ground Water Ref/Year ; Average ArnAt Precipitation An 14 10-25 <br /> On-Site Weit(s) Yes No Number & Type Irr Oom Pub <br /> S Score S Scare S Score <br /> Distance to W@LL(s) from Yank ft; ft; ft C 10 pts, C 9 pts C 5 pts <br /> 0 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 Soil Sample (feet) >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) Nona Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx 410 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) Nona Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby sells. At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + + a <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T X E <br /> MAXI ALLOWABLE B-T•X-E LEVELS (PPN) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPN LEVELS ( ) <br /> TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: '**If documented soil and/or ground water contamination is present, do not complete the teaching potential <br /> analysis. (i.e., site is currently an 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 STX&E are not applicable at a TPH concentration of 10 ppm (gasotine) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPN Concentrations > Allowable Levels *Yes No <br /> 2. Recamamid 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 YES NO REF TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH Z3 80 (UGTWKSHT)\5/90 <br /> 1 <br />