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f <br /> SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I. 1AhL WORKSHEET FOR SITE CLOSURE EVALUATION DATE / <br /> NAME OF FACILITY SWEEPS CODE <br /> ADDRESS ?AHK ID # <br /> TANK SIZE �foo(> FUEL TYPE e5 <br /> II. GENERAL SITE HISTORY <br /> rs* <br /> Is permit current? Yes No Permit # - Facility Status Code Doc.Soil/GW Cont Yes No <br /> Number of Tanks at fae lity Age of Tanks(if available) � t of Tank Steel Fbrgl Sngl Dust <br /> III. TANK HISTORY <br /> Was Tank tested? YesJ'xluo Failed precision test ? Yes No if yes, give dateOT <br /> Was a repair made to the tank system? Yes No if yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH•G TPH-D Pb/EDB <br /> 11 — <br /> Type of failure/discharge catastrophic long-term leakage overfill univ�own other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soft Samples Received Yes No Depth to Ground Wateref/Year ; Average Annual Precipitation A=114 10-25 <br /> On-Site Welt(s) Yes No Number i Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to Welt(s) from Tank 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 Soft Sample (feet) >100 51-100 25.50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 10-25 xxx)o= 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> COLUMN <br /> COLUMN TOTALS>»TOTAL POINTS ; 14 7 <br /> Sample Result: J(B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 7 48 pts 40 pts or less <br /> B 1 T X E BJT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. HA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 7 100 <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 4=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 TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION �� <br /> 1. Are BTX A E or TPN Concentrati > Allowable Levels *lies No `~'fir ' •{/\ <br /> 1 <br /> 2. Recoamend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR /�fi G O' <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 • • <br />