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SAN IOAOUIN COU*gLIC HEALTH SERVICES/ENVIRONMENTAL HEALT VISION <br /> UG .lORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY { <br /> v P ( 04,1 SWEEPS CODE / <br /> ��ADDRESS TANK ID 9 � <br /> j TANK SIZE I ZE /" 000 FUEL TYPEb <br /> `o -ArcSt <br /> iI. GENERAL SITE HISTORY <br /> I's permit current? Yes - No Permit # *** <br /> Facility Status Code (j;�/ Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facilityTanks(if avaiLable) Type of Tank SteeE Fbrgl Sngl peal <br /> TANK HISTORY <br /> aas Tank tested? No Failed precision test ? Yes No ✓' If yes, give <br /> *les a repair made to the tank system? Yes No If yes, what was repaired? <br /> 4as repair done under inspection? Yes No were soil samples analyzed? Yes No BTX€ TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic Long-term leakage overfill unknown other: <br /> V. REMOVAL 4ISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes ✓ No Depth to Ground watMer7AeraePrecipitation Am 14 10-25 <br /> lOn-Site Well s) Yes No I-- Number & Type Irr <br /> e S Score <br /> Distance to WeIL(s) from Tank ft; ft; sC 5 pts <br /> 0 if <br /> ition R condition <br /> V. Site Feature - Leaching Potential Analysiset E is met <br /> 7MinimumDepth togroundwater from the Soil Sample (feet) >100 51-100 25-50\1 <br /> s in subsurface (applies to foothills or mountain areas) J Q 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 �� + �-7 + - <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts orless <br /> B 7 X E 8 T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 $0 50 .3 .3 1. 1. NA\3 <br /> Sample Resuit: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPN 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 sail 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 TAH concentration of 10 Ppm (gasoline) or 100 ppm (diesel).. <br />'I. STAF= IECOMMENDATION/CONCLUSION <br />=1Ar,? E or TPH Concentrations > Attowable Levels *Yes Ho <br /> 2. Recormend Site CLosure Yes No If Yes, Refer to site Mitigation for Evaluation <br /> II. 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 NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />