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SAN JOAQUIN Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL (VISION <br />• UGST WORKSHEET FOR SITE CLOSURE EVALUATION (DATE <br />i <br />, <br />NAME OF FACIL17Y (SWEEPS CODE <br />I <br />ADDRESS (TANK ID wi - <br />!TANK SIZE[ (FUEL TYPEI <br />Ii. GENERAL SITE HISTORY <br />*** <br />i I <br />Is permit current? Yes Nol Permit #� - Facility Status Codel Doc.SoiL/GW ContlYesl !NoI <br />Number of Tanks at facility) Age of Tanks(if avaiLable)l (Type of Tank Steep lFbrgll lSngl Duall <br />I::. TANK HISTORY <br />iWas Tank tested? Yesl INoI (Failed precision test ?�Yesl INoI lif yes, give date(s) <br />Was a repair made to the tank system?IYesl Nol Iif yes, what was repaired? <br />Was repair done under inspec:ion?lYes� INoI (Were soil samples analyzed?lYesl INoI IBTXEI ITPH-GI ITPH-DI IPb/EDBI <br />Type of failure/discharge) [catastrophic) (long-term leakage) Ioverfilll !unknownI )other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />ISoiL Samples ReceivedlYesl INol IDepth to Ground Water <br />!Ref/Year) [Average Annual Precipitation <br />A=114 10-25! <br />IOn-Site Well(s)'YesINoI <br />I <br />[Number & Type lirrl <br />i <br />Danl [Pub <br />S Score <br />C 10 pts <br />0 if <br />R condition <br />E lis met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />9 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />5 pts <br />if <br />condition <br />is met <br />(Distance to WeIL(s) from Tankl ', ft; 4t <br />!V. Site Feature - Leaching Potential Analysis <br />!Minimum Deoth to groundwater from the Soil Sample (feet) I <br />l >100 I 151-100 <br />I 125-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) I <br />I None ( <br />Unknown I (Present i <br />[Average Annual Precipitation (inches) <br />�xxxxxxi <10 I 9 110-25 <br />Ixxxxxxxl 26-40\2 <br />!Man -Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water wells, ponds) <br />I None <br />I <br />Unknown <br />I <br />(Present <br />!Unique site features: Recharge area, coarse soil, nearby wells. <br />I <br />xxxxNone <br />xx <br />I <br />At least) <br />one <br />More than <br />one <br />COLUMN TOTALS» >TOTAL POINTS <br />i + <br />i <br />!Sample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS:49 <br />pts or more I 41 - 48 pts I 40 pts or less ! <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM)) <br />31 <br />11 <br />50 <br />50 <br />50 <br />.3 <br />3 <br />I.T <br />1 <br />1. <br />NA\3 <br />(Sample Result: <br />TPH <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />GASOLINE) <br />1000 I 100 I 10 <br />DIESEL <br />10,000 l 1000 l 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 BTX&E are not applicable at a TPN 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 Nol <br />2 Recommend Site ClosurelYesj No;* <br />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 CLOSUREIYESI INOI IREFERRED TO SITE MITIGATION FOR EVALUATION YES! INOI <br />!DATE REFERRED! / / (DATE CLOSURE LETTER MAILED <br />(NAME OF <br />EVALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />