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SAN JOAQUIN _"Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL Ht^DIVISION <br /> I' yZf WORKSHEET FOR SITE CLOSURE EVALUATION ATE 3. <br /> A►+E Of FACILITY At Y\�1 iAb,Q ` , SWEEPS CODE Z Ll 2' <br /> OGRESS l C 4-,r,ne I 5 -tY� TANK ID # <br /> TANK SIZE 5W UEL TYPE (�5 <br /> It. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # acitity Status Code J oc.Soil/GW Con es o <br /> umber of Tanks at facility 3 ge of Tanks(if available) I t)n`L ype of Tank teet Fbrg( I ngt Dual <br /> III. TANK HISTORY <br /> was Tank tested? eso ailed precision test ? es o if yes, give date(s> <br /> as a repair made to the tank system? es No 11f yes, what was repaired7 <br /> Jas repair done under inspection? es go I Pere soil samples analyzed? Y XE <br /> es Jo I TXE PH-G PH-0 b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfitl known ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FCR LEACHING POTENTIAL ANALYSIS) <br /> LLAI <br /> oil Samples Received es o epth to Ground Water of/Year i`v' verage Annual Precipitation = 4 10-25 <br /> -Site Welts) es o umber & Type Irr am ub <br /> S Score S Score S core <br /> istance to Welt(s) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R condition R condition R ondition <br /> 0. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feety� U ` >100 1-100 Jj 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) Note Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26-40\2 <br /> i <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> Inique site features: Recha_r_ge area, coarse soil, nearby wells. At least lore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + 3C� + q l <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> KD 2. -(-tjD2. --J <br /> x _ CL`. B T X E a T I X E <br /> 11) MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: SO INE 1000 100 10 <br /> AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> 3,aD0 TPH:ppyrl IESEL 10,000 1000 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 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 STX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION NU�r_; f U 1-4-1 <br /> 1. Are BTX & E or TPH Concentrations > Allowable LevelsYes o fo3 pew, <br /> 2. Recommend Site Closure IYes o I Y, If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR V <br /> CNCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF r <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br /> . . . 4- 1 a.. - a a <br />