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SAN JOACUIN PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL VISION <br /> t. WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY } SWEEPS COOS t' ° <br /> EEs:s A TANK ID 11 - ;.® <br /> TANK SIZE FUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> *** <br /> Is permit current? Yes No Permit >e - Facility Status Code Doc.Solt/GW Cant Yes IxNo <br /> Al <br /> Mumiber of Tanks at facittty Age of Tanks(if available) Type of Tank Suet Fbrgl Sngl I Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes NNo Failed precision test ?11 No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? f <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE' PM-(; TPN-0Pb/EDB v . <br /> Type of failure/discharge catastrophic lag-term leakage overfill lunknowniother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water Hof/Year ; Average ArvvAt Precipitation A= 14 10-25 <br /> On-Site WeLL(s) Yes No am r L Type Irr DPub <br /> S Score S Score S Score <br /> Distance to Well(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 /> Minimsm Depth to gr ter from the Solt Sampte (feet) >100 51.100 25-50®1 <br /> Fractures in subsurface (applies to foothills or mountain areas) MGM Unknown Present <br /> Average Annual Precipitation Cinches) <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-made conduits which increase vertical, migration <br /> of teachate (i.e., septic systems, water wits, ) maw Urdawwlft Present <br /> Unique site features: Recharge area, coarse soil, nearby watts. At least More than <br /> None one ane <br /> COLUMN TOTALS>»TOTAL POINTS + + ' <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 /> MAXIMA ALL LE 3•T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: INE 1000 100 10 <br /> MAXI ALL lE TPN LEVELS (PPM) <br /> TPN DIESEL 101000 1000 100 <br /> FOOTNOTES: *"If documented soil and/or ground "ter contamination is Xwent, 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 BTXSE are not applicable at a TPN concentration of 10 ppm Cgesoline) or 100 ppm (diesel). <br /> VY. STAFF RE NDATIOM/CONCLUSIOM <br /> 1. Are BTX Ii E or TPH Concentrations > Attowablo Levets *Yes ELI <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Sita Mitigation for Evaluation <br /> Vit. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> COMLIuR WITH STAFF R£ NOATION FOR CLOSURE YES NO RE TO SITE 14 GATYON FOR EV TI YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED / / <br /> NAME OF <br /> EVALUATCR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />