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SAN JOAOUIN COU <br /> N:wr 4BLIC HEALTH SERVICES/ENVIRONMENTAL HEALTY_.,SION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY SWEEPS CODE / <br /> Z <br /> ADDRESS / TANK ID # - <br /> TANK SIZE FUEL TYPE <br /> [I. GENERAL SITE HISTORY <br /> N* <br /> Is permit current? Yes No Permit # - Facility Status Cade Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility •Z/- Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> 111. TANK HISTORY <br /> Was Tank tested'! Yes No Failed precision test 7 Yes No IXTIf yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? n <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-C TPH-D Pb/EDB <br /> Type of failure/discharge eatastroph is tong-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 No Depth to Ground Water Ref/Year Average Annual Precipitation A= 14 10-25 <br /> On-Site Wells) Yefro <br /> s No Number 8 Type Irr Dom Pub <br /> S Score S Scare S Score <br /> Distance to Wells) m Tank ft; ft; ft C 10 pis C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet)40— >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) D 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 No a one one <br /> COLUMN TOTALS»>TOTAL POINTS I O 1 - A-7 <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more - 48 pts 40 pts or less <br /> C =Tx' E�T• B T X E g T E <br /> D 1 21 V y MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sa/m�ple Resul�t GASOLINE 1000 100 10 <br /> ?'11aF a)>1�O0 T'� MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH�/ D[ESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do t couple the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for s 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. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/ IOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YE4111 <br /> NO REFERRED TO SITE MITIGATION FOR EVALUATION YES <NOI <br /> DATE REFERRED / / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EN 23 80 (UGTWKSHT)\5/90 <br />