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SAN JOAQUIN bX4TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA-4 DIVISION <br /> I, UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> INANE OF FACILITYSWEEPS CODE V4f <br /> !ADDRESS TANK ID # <br /> TANK SIZE FUEL TYPE <br /> I1. GENERAL SITE HISTORY <br /> H* <br /> FIs permit current? Yes No Permit # pR -/Y'7701Z Facility Status Code ©/ Doc.Soit/GW Cont Yes No <br /> 'Number of Tanks at facility / Age of Tanks(if available) Type of Tank Steell✓ Fbrgll ISngll Dual <br /> 111. TANK HISTORY <br /> ,Was Tank tested? Yes No Failed precision test ? Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> ''Was repair done under inspection? Yes No Were soil samples analyzed?11 Yes No BTXE TPH-G TPH-D Pb/EDB <br /> ,Type of failure/discharge catastrophic Long-term Leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> -Sail Samples Received No Depth to Ground Water �Q Ref/Year Average Arcual Precipitation A- 14 10-25 <br /> Y s <br /> On-Site Wells) Yes No Number 8 Type Irr Dao Pub <br /> S Score S Score S Score <br /> Distance to Wells) frac Tank !✓ ft; ft; ft C 10 pis C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R conditionLR condition R condition <br /> IV. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> iMinisa <br /> mn Depth to groundwater from the Soil Sample (feet) >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or muntain areas) 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 /> lof leachate (i.e., septic syste , water wells, ponds) None Unknown Present <br /> �Unique site features: Recharge area, coarse soil, nearby wells. /` At least More than <br /> None <br /> (/� <br /> xxxxxx one one <br /> COLUMN TOTALS»>TOTAL POINTS + 2� + ✓ �fv <br /> !Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> I B T X E B T X E <br /> I N-9 . MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. MA\3 <br /> ;Sample Result- GASOLINE 1000 100 10 <br /> piY , g �H� MAXIMUM ALLOWABLE TPN LEVELS (PPM) DIESEL 10,000 1000 100 <br /> (FOOTNOTES:4rW (•�••*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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recaimend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation <br /> V(I. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES t/NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />