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SAN JOAQUIN CO Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL —DIVISION � O <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION GATE <br /> (NAME OF FACILITY / SWEEPS CODE <br /> 'ADORESS Y j TANK ID # - <br /> TANK SIZE - 60 1 FUEL TYPE <br /> Il. GENERAL SITE HISTORY <br /> rrr <br /> is permit current? Yes No Permit # - Facility Status Code Doc.Soi L/GW Cont Yes No <br /> (Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl SngL Dual <br /> Ill. TANK HISTORY <br /> �4as Tank tested? Yes No Failed precision test ? Yes No tf 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 INo BTXE TPH-GI TPH-01 I 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 V No Depth to Ground WaterRef/Year l� Average Annual Precipitation A= 14 10-25 <br /> Ion-Site WeLL(s) Yes No Number 8 Type Irr Dom Pub <br /> 5 Score S Score S Score <br /> Distance to Well(,) 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 /> jV. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) X0 ",ne <br /> Unknown Present <br /> Average Annual Precipitation (inches) 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> jof Leachate (i.e., septic systems, water wells, ponds) Unknown Present <br /> iUnique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> 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 /> B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> ? H-C 1 n/D MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> -�/.}_ n ; kM TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: ---[f 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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> Vt. STAFF RECOMMENDATION/CONCLUSION 2c? t--0 Q/tq V1r L�v <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels -Yes No IND . <br /> 0 <br /> 2. Recommend Site Closure Yes No -It 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 x' NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO x <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF -k <br /> EVALUATOR �T-v I <br /> EH 23 80 (UGTWKSHT)\5/90 <br />