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SAN JOAQUIN COON,,.�BLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH BASION <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY SWEEPS CODE <br /> ADDRESS TANK ID #jyj <br /> l53 - ol <br /> TANK SIZE FUEL TYPE U <br /> 11. GENERAL SITE HISTORY <br /> e** <br /> Is permit current? Yes �n No Permit # - Facility Status Code Doc.Soil/GW Cont Yes Na <br /> Number of Tanks at facility Age of Tanks(if aysi Lable) Type of Tank Steel Fbrgl SngL Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? Yes XNo Failed precision test ? Yes No If yes, give date(s) 7//G A; <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? ' <br /> Was repair done under inspection? Yes No x Were soil samples analyzed? Yes No BTXE TPN-G TPH-O 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 /> Soil Samples Received Yes ll No Depth to Ground Water Ref/Year Average Amual Precipitation A-114 10-25 <br /> On-Site Wetl(s) Yes No Number & Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to WeIL(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 coalition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Mini mun Depth to groundwater from the Soil Sampte (feet) >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain 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 /> 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 more 41 - 48 pts 40 pts or less <br /> N ND <br /> B T % E B T % E <br /> r. S AL MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Re ult: n 1 D �IMIA( ALLOWABLE TPH LEVELS (PPM) GA CLINE 1000 100 10 <br /> K' S TPH Cs DIESEL 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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION f(l,AAw• II^nnYI /�,.,_�A/ �1— / <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels -Yes No ' �"•`-V� � `�",V"� fi�B�i <br /> 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evatuation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES Mol I <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED / / <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />