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OF FACILITY <br />hANK SIZE <br />'I. GENERAL SITE HISTORY <br />SAN JOACUIN CCUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALT ISION <br />UGs, WORKSHEET FOR SITE CLOSURE EVALUATICN ATE c <br />ISWEEPS CODE I ( 17q� <br />i� ANK IO # I - <br />UEL TYPE <br />Is permit <br />current7 <br />es <br />o <br />o <br />Vfermit <br />/l <br />- <br />acility Status Code <br />If <br />oc.Soil/GW <br />Cont <br />es <br />ITf yes, what was repaired7 <br />o <br />as repair done under inspectionj <br />uanber of <br />Tanks at <br />facility <br />o <br />ge of Tanks(if availableD <br />TXE <br />ype of Tank Leet <br />PH -G <br />fbrgl <br />ngl <br />Oual <br />It. TANK HISTORY <br />ms Tank tested?EE <br />es <br />o <br />IF <br />ailed precision test Y <br />es <br />/Year <br />o <br />If <br />yes, give date(s) <br />/ <br />Jas a repair made to the tank system? 1Yes No I <br />ITf yes, what was repaired7 <br />es <br />as repair done under inspectionj <br />es 40 ere soil samples analyzed? <br />es <br />8 Type <br />o <br />11 r <br />TXE <br />am <br />PH -G <br />PH -0 <br />WEDS <br />ype of failure/discharge <br />atastrophic long-term leakage <br />verfilt <br />known1 <br />Cher: <br />10 <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received <br />es <br />o <br />epth to Ground {later <br />- <br />13 � <br />/Year <br />� ; <br />verage Annual Precipitation <br />= <br />4 <br />0-25 <br />-Site Wells) <br />es <br />0r <br />8 Type <br />11 r <br />am <br />ub <br />S <br />core S <br />core <br />S <br />core <br />istance to Nett(s) from Tank <br />ft; ft; ft <br />C <br />10 pts C <br />9 pts <br />C <br />pts <br />if 0 <br />if <br />0 <br />f <br />0 <br />onditicn R <br />condition <br />R <br />ondition <br />R <br />Site Feature - Leaching Potential Analysis <br />E <br />s met E <br />is met <br />E <br />is met <br />inimum Depth to groundwater from the Sotl Sample <feet) <br />>100 <br />1-100 <br />25-50\1 <br />ractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />resent <br />%verage Annual Precipitation (inches) KXXXXX <br /><10 9 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />on -made conduits which increase vertical migration <br />I leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />resent <br />pique site features: Recharge area, coarse soil, nearby wells. <br />At least <br />lore than <br />xxxx <br />None <br />one <br />one <br />COLUMN TOTALS>>>TOTAL POINTS <br />+ <br />+ <br />ampte Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts <br />40 pts or less <br />B T X E B T X E <br />MAXIMLl4 ALLOWABLE B -T -X -E LEVELS (PPM) <br />1 50 50 50 .3 .3 1. 1. <br />NA\3 <br />ample Result:ASOLINE <br />1000 100 <br />10 <br />AXIMUM ALLOWABLE TPH LEVELS (PPM) <br />TPH IESEL <br />10,000 1000 <br />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 <br />water.) <br />\1 if depth is > 5 ft. and < 25 ft., score 0 points. if <br />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 <br />ppm (diesel). <br />`dl. STAFF RECCMMENDATION/CONCLUSION <br />1. Are BTX $ E or TPH Concentrations > Allowable Levels Yes o <br />2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br />11. REVIEW EVALUATION - TO BE CCMPLETED BY A SUPERVISOR/SENIOR <br />CONCUR WITH'STAFF RECOMMENDATION FOR CLOSURE <br />YES <br />0 <br />EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br />ATE REFERRED <br />/ / <br />ATE CLOSURE LETTER MAILED <br />LAME OF <br />:VALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />