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SAN JOAQUIN —"OT <br /> Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL H P4` OIVtSION <br /> I• WORKSHEET FOR SITE CLOSURE EVALUATION DATE 17-3— <br /> NAME OF FACILITY C t SWEEPS CODE f 7 <br /> ADDRESS i TANK ID # - <br /> TANK SIZE &j 0 FUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Yes MNo Permit it (Facility Status Code 11 Doc.SOiL/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) (Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes Failed precision test ?1Yes No If yes, give dates) <br /> No <br /> Was a repair made to the tank system? Yes` No IIf yes, what was repaired? S <br /> Was repair done under inspection? Yes xNo Were soil samples analyzed?I Yes No BTXE I ITPH-G TPH-0 Pb/EDBI <br /> Type of failure/discharge catastrophic long-term leakage overfill Iunknown I other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water Ref/Year Average Annual Precipitation A= 14 110-25 <br /> On-Site Welts) Yes No Number & 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 met E is met <br /> 1Minimum Depth to groundwater from the Soil Sample (feet) I .100 I51-100 I 125-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) I None Unknown I (Present <br /> Average Annual Precipitation (inches) XXXXXXI <10 1 9 1 10-25 1xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknon 5 (Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. I At least More than <br /> xx)o= None one one <br /> COLUMN TOTALS»>TOTAL POINTS + ! + JID <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 - 48 pts 40 pts or Less <br /> S T X E B IT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50I 50` 50 .3 .3 1.� 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PAM) <br /> TPHDIESEL 10,000 1000 I 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the ing potentia <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground <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 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( N01 REFERRED TO SITE MITIGATION FOR EVALUATION YES IND <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED / ! <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />