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1 <br />-" <br />SAN <br />JOAQUIN b. ATY PUBLIC HEALTH <br />UGST WORKSHEET FOR <br />SERVICES/ENVIRONMENTAL H(`fl DIVISION <br />SITE CLOSURE EVALUATION <br />GATE <br />7 ' �� <br />NAME OF <br />FACILLITYr� <br />Average Ar%wal Precipitation <br />06 <br />14 10-25 <br />SWEEPS CODE <br />a 3 b <br />ADDRESS <br />/j I % <br />G , <br />�% <br />fD (�/ 1 TrJY_ <br />TANK [D #13t?- <br />/D / " _ <br />TANK S12E FUEL <br />(I. GENERAL SITE HISTORY <br />TYPE V <br />/Dj p njce_� <br />gee <br />is permit current? <br />Yes <br />No <br />I TPH-G <br />Permit # <br />TPN -0 <br />Facility Status Cade <br />Doe.SoiL/GW <br />Cont <br />as <br />catastrophic <br />No <br />long-term leakage <br />'Number <br />of Tanks at <br />facility <br />Age of Tanks(if <br />available) <br />Score <br />10 pts <br />Type of Tank <br />Steel <br />S <br />C <br />Fhrgl <br />D'stance to WeLL(s) from Tank <br />Sngl <br />Oual <br />III TANK <br />HISTORY <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />O <br />R <br />E <br />:Was Tank tested? <br />Yes <br />NO <br />No <br />TES <br />Failed precision test ? <br />Yes <br />Ref/Year <br />No <br />Average Ar%wal Precipitation <br />If yes, give date(s) <br />14 10-25 <br />'!Was a repair made to the tank system? <br />Yes <br />No <br />No <br />If yes, what was repaired? <br />N 8 Type <br />uas repair done under inspection? <br />Yes <br />No <br />Were sail samples ana Lyzed? Yes <br />No <br />BTXE <br />I TPH-G <br />TPN -0 <br />Pb/EDB <br />!Type of failure/discharge <br />catastrophic <br />long-term leakage <br />overfill) unknown <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING PUILMIIAL ANALT]Ia) <br />p7 <br />P a= <br />P 3J <br />Soil Samples Received <br />Yes <br />NO <br />No <br />TES <br />Depth to Ground Water <br />NO <br />Ref/Year <br />Average Ar%wal Precipitation <br />A= <br />14 10-25 <br />jOn-Site Well(s) <br />Yes <br />NAME OF <br />EVALUATOR <br />No <br />N 8 Type <br />Irr <br />Dom <br />Pub <br />S <br />C <br />Score <br />10 pts <br />S <br />C <br />Score <br />9 pts <br />S <br />C <br />Score <br />5 pts <br />D'stance to WeLL(s) from Tank <br />ft; ft; ft <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />O <br />R <br />E <br />if <br />condition <br />is met <br />jV. Site Feature - Leaching Potential Analysis <br />;Mini mum Depth to groundwater from the Sail Sample (feet) <br />>100 <br />51-100 <br />D <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />D <br />None <br />Unknown <br />Present <br />)Average Annual Precipitation (inches) <br />xxzxxx <br /><10 <br />9 1 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />iMan-Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />Present <br />site features: Recharge area, coarse soil, nearby wells. <br />At least <br />More than <br />(Unique <br />xxxxxx <br />Nene <br />q <br />ane <br />o>e <br />D <br />• <br />' <br />' <br />- <br />COLUMN TOTALS»)TOTAL POINTS <br />c� <br />O <br />'Sample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />41 - 48 pts <br />�rO s N1) x. <br />,yam Si gf <br />B T <br />X <br />E <br />8 <br />T <br />% E <br />AE -0,053 % <br />MAXI LKQWASLE B -T -%-E LEVELS (PPM) <br />1 50 <br />50 <br />50 <br />.3 <br />.3 <br />1. 1. <br />NA\3 <br />ISamole Result: <br />GASOLINE <br />1000 <br />100 <br />10 <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />ft S:2t, % TPX <br />DIESEL <br />10,000 <br />1000 <br />100 <br />',FOOTNOTES: •" If documented soil and/or ground water contamination is present, do not complete the po ential <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., scare 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 ppn (gasoline) or 100 ppm (dieseU. <br />11I. STAFF RECOMMENDATION/CONCLUSION �_ora�& 0(�af iLv q <br />1. Are BTX 8 E or TPN Concentrations > Allowable Levels -Yes 1xi <br />No <br />2. Recommend Site Closure Yes Na f Yes, Refer to Site Mitigation for Evaluation al <br />•I _ a <br />1111. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE <br />YES <br />NO <br />REFERRED TO SITE MITIGATION FOR EVALUATION <br />TES <br />NO <br />DATE REFERRED <br />/ / <br />DATE CLOSURE LETTER NAILED <br />NAME OF <br />EVALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />