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SAN JOAOUIN�NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL `JTH DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE '71-Z <br /> NAME OF FACILITY % iJ �C r to Lv SWEEPS CODE <br /> ADDRESS - 67- TANK ID # -Sri - Qy <br /> TANK 512E 3S , FUEL TYPE 6W g <br /> IL GENERAL SITE HISTORY <br /> ** <br /> Is permit current? Yes No Permit # Facility Sta s Code Doc.soil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank I SteelFbrgl I ISngl Dual <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 TPH-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 ,� Ref/Year O Average Annual Precipitation A= 14 10-25 <br /> On-Site Well(s) Yes No Number 8 Type Irr Dan I Pub <br /> S Score S Score S Score <br /> Distance to Wells) 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 /> Minimum Depth to groundwater from the Soil Sample (feet) 'Q.(Q >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 .7 one <br /> COLUMN TOTALS>»TOTAL POINTS $ + /v <br /> Sample Result,:, (8/T^X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> AIN o** y L 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 /> Samp FAesuL dye GASOLINE 1000 100 10 <br /> 1JO ��� MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 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. Ppm (diesel). <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 PP^� (gasoline) or 100 <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX d E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes o *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 A <br /> EVALUATOR <br /> EH 23 a0 (UGTWKSHT)\5/90 <br />