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SAN JOAQUIN COUNAI&JBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH SION DATE ry <br /> U RKSHEET FOR SITE CLOSURE EVALUATION Q <br /> NAME OF FACILITY �� yt� SWEEPS CODE �� <br /> ADORESS <br /> / ��� TANK ID # - / — <br /> i/~— <br /> TANK SIZE <br /> FUEL TYPE <br /> GENERAL SITE HISTORY *** <br /> Lsp ermit current? Yes No Permit # Facility Status Code 0� Doc.Soit/GW Cont YesNer of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngt Dual <br /> I. TANK HISTORY <br /> Was Tank tested? Yes X No Failed precision test ? Yes No dates) <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-0 Pb/EDB <br /> Type of failure/discharge catastrophic Long-term leakage ov.r+i111 I unknown other: <br /> !. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> / Average Annual Precipitation A=114 10-25 <br /> EOn-Site <br /> Samples]Rec2eived%3gDepth to Ground Water �(} Ref/Year 0[� <br /> W®LL & Type Irr Dom Pub <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 +ret E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet),5(�}•'i <br /> )100 51-100 ,rj 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) I None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xx 26-40\2 <br /> Man-Made conduits which increase vertical migration No <br /> Unknown Present <br /> of leachate (i.e., septic systems, water welts, ponds) <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx No <br /> one one <br /> COLUMN OTALS>>>TOTAL POINTS V 3 <br /> Sample R s • (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts pts or less <br /> t <br /> B IX501 <br /> E B T X EMAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 .3 .3 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPN DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete a eaching pot <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or grotqd wa er. <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 Le-ets *Yes No <br /> 2. Recommend Site Ctosure Yes INC 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 REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED 1 / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />