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SAN JOAQUIN C* PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL�)IVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE 8IZ812000 <br /> NAME OF FACILITY Co rLt&/1 SWEEPS CODE <br /> ADDRESS 11411 I S i r n ov, II `Iw TANK ID # GJIG�-o5 <br /> TANK SIZE FUEL TYPE S <br /> 11. GENERAL SITE HISTORY , <br /> Is permit current? Yes No Permit # - Facility Status Cade Doc.Soit/GW Cont Yes No <br /> Number of Tanks at facility Age of I nks(if available) Type of Tank Steel Fbrgl Sngl I Dual <br /> 111. TANK HISTORY <br /> Wes Tank tested? Yes No Failed precision test ? Yes No. If yes, give date(s) <br /> !Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-GI TPN-D 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 X I No Depth to Ground Water 35 Ref/Year S 3;g(p Average Annual Precipitation A=114 10-25 <br /> On-Site Welt(s) Yes No >(Q I Number & Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to WeI.L(s) from Tank ft; ft; ft C 10 pts C 9 pis 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 /> ?Mini mum Depth to groundwater from the Soil Sample (feet) >100 51-100 25-50\1 <br /> fractures in subsurface (applies to foothills or mountain areas) I p None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> ;Nan-Made conduits which increase vertical migration <br /> iof leachate (i.e., septic systems, water wells, ponds) O None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. n At least More than <br /> Xxxxxx None _! one r (�,one <br /> i <br /> COLUMN TOTALS>>>TOTAL POINTS O + I + 5 = IJ <br /> jSample Resul - (B X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> N�-x tStl- (� <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 9 50 50 50 .3 .3 1. 1. NA\3 <br /> jSa pLe Result: GASOLINE 1000 100 10 <br /> �'^`6 MAXIMUMMAXIMUMALLOWABLE TPH LEVELS (PPM) � <br /> TPH A DIESEL 10,000 1000 100 <br /> FOOTNOTES: "*If documented soil and/or ground water contamination is present, do not complete the Leaching potentiaL II <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 /> Vt. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPN Concentrations > At Lowable Levels "Yes NoFZ <br /> 2. Recommend Site Closure Yes No 'If Yes, Refer to Site Mitigation for EvaluatiW <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLMREIYEW NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DA CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH Z3 80 (UGTWKSHT)\5/90 <br />