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I SAN JOAQUIN r -fNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEB'TH DIVISION / <br /> r ;SI WORKSHEET FOR SITE CLOSURE EVALUATION j DATEF/ <br /> / l 7 <br /> N-%qg OF FACILITY L SWEEPS CODE( <br /> ADDRESS S. �� CEJ TANK ID it <br /> TANK SIZE FUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> m <br /> Is permit current? Yes No Permit - Facility Status Code119,11 <br /> Doc.Scit/GW Coni Yes INoI <br /> Number of Tanks at facility �.l Age of Tanks(if available) Oj Type of Tank Steel Fbrgl Sngl Out <br /> d <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precisiontest ? Yes No It yes, give dates) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes Nal Were sail samples analyzed? Yes No BTXE TPH-G TPH-0 Pb/ED8j <br /> Type of failure/discharge catastrophic (long-term leakage overfill unknown 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 10-25 <br /> On-Site WeLL(S) Yes No Number & Typel Irr Dam 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 /> Minimum Depth to groundwater from the Soil Sample (feet)yb - ` >100 51-100 5 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas 10 None Unknown Present <br /> (Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 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 TOTALS»>TOTAL POINTS <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or mor 41 - 48 pts 44-pts'ar-les\ <br /> g� ,Dlpp B T X E B T X E <br /> `� 1 -- .D rw MAXIMUM ALLCSUABLE B-T-X-E LEVELS (PPM) 1` 50 50 50 ..3 .3 1. 14 `NA\3 <br /> Sample Result:�D '016 GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPN LEVELS (PPM) -,• <br /> Pith DIESEL 10,000 1000 $(j <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do t complete . efehiaq-potent A <br /> analysis. (i.e., site is currently on UGT Contamination List for soi 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 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 Closure IYes No If Yes, Refer to Site Mitigation for Evaluation Gx�� <br /> VII. REVIEW EVALUATION TO BE COMPLETED SY A SUPERVISOR/SENIOR U <br /> CONCUR WITH STAFF RECCMMENDATION FOR CLOSZIREIYES �jNO REFERRED TO SITE MITIGATION FOR EVALUATION YES V✓ NO <br /> DATE REFERRED i / / DATE CLOSURE LETTER MAILED <br /> NAME OF _ <br /> EVALUATOR( <br /> EH 23 80 (UGTWKSHT)\5/90 <br />