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SAN JOAQUIN L,.,TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE. DIVISION 1-� <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION -W DATE ! s5 97 <br /> NAME OF FACILITY SWEEPS CODE <br /> ADDRESS TANK ID # - ' (� L4 5 <br /> TANK SIZE 1 y)QFUEL TYPE S,j4,, D <br /> 11. GENERAL SITE HISTORY <br /> www <br /> Is permit current? Yes No Permit # - Facility Status Code Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility ' Age of Tanks(if available) Type of Tank Steel X lFbrgtl Sngl oual <br /> 111. TANK HISTORY <br /> Was 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-G 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 No Depth to Ground Water i;� Ref/Year 5 ;q Average Annual. Precipitation A= 14 10-25 <br /> On-Site WeIL(s) Yes No Number & Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to Wells) 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 /> V. Site Feature - Leaching PotentiaL Analysis E is met E is met E is met <br /> Minimus Depth to groundwater from the Soil Sample (feet) -6 f:4- >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) 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 I + ♦ S = (4/ <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> —ND ..•OOi <br /> ND -•oor. B TX E B T % E <br /> - S' MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> S ?_I Result_: ,,�•� GASOLINE 1000 100 10 <br /> N11 '.�E-•r.;- ' MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> Tom{-1.2 1Apn,TP 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. 1f 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 /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & 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/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 />