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SAN JOAQUIN COUNI ,BLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH 'SION <br /> • UGS, -WRKSHEET FOR SITE CLOSURE EVALUATION DATE Iz Tr:�;7 <br /> NAME OF FACILITY �on�r-� GvL,,. SWEEPS CODE <br /> ADDRESS <br /> BANK SIZE �� FUEL TYPE 14,,;-C,,- <br /> 1. <br /> 4,,;-1. GENERAL SITE HISTORY <br /> Is permit current? Yes No I Npermit # - Facility Status Code - I Doc.Soil/GV Con[ Yes No <br /> �Nunber of Tanks at facility I Age of Tanks(if available) (1. KC .(Type of TanklSteelI IFbrgtI ISngII Dual <br /> ' !I. TANK HISTORY <br /> 'was Tank tested? Yes No Failed precision test 7 Yes No If yes, give date(s) <br /> Jas a repair made to the tank system? Yes No If yes, what was repaired? <br /> Jas repair done under inspection? Yes No Were soil samples ana Lyxed?r,,k,,w, <br /> No BTXE TPH-G TPH-D Pb/EDType of failure/discharge catastrophic long-term leakage overfill other: <br /> REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> '.Soil Samples Received Yes No Depth to Ground Water" <br /> of/Year 5Tfc Average Arcual Precipitation A= 14 10-25 <br /> ,3n <br /> -Site WeIL(s7 Yes No Number & Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to eel L(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 condition R condition <br /> ,J. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> !nimum Depth to groundwater from the Soil Sample (feet) -Tj Zj >100 51-100 5 125-50\1 <br /> -actures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> -age Annual Precipitation (inches) xxxx'X <10 9 10-25 xxxxxxx 26-40\2 <br /> �an-Made _onduits 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 ane e <br /> � on <br /> J <br /> COLUMN TOTALS>>>TOTAL POINTS + ' `7 I <br /> (Sample Result: (3 T X OR E RANGE OF TOTAL POINTS 49 pts or more 1 - 48 40 pts or Less <br /> 'OZ�PP^a 3T X "c 8 T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sade Result:PP GASOLINE 1000 100 10 <br /> 2 S MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH 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 3TX&E are not applicable at a TPH concentration of 10 ppn (gasoline) or 100 ppm (diesel). <br /> 'Jt. STAF= 2ECOMMENDAT ION/CONCLUSION I-6A A nl <br /> I. Are BTX & E or TPH Concentrations > Allowable Levels -Yes No <br /> .. Reranmerd Site Closure Yes No •tf Yes, Refer to Site Mitigation for Evaluation - <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES l% NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED / / <br /> NAME OF <br /> EJALUATOR ll" <br /> Eli 23 80 (UGTWKSHT)\5/90 <br />