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SAN JOAQUIN CCr _f PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA. DIVISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME Of FACILITYC J SWEEPS CODE � <br /> ADDRESS �. A _ i1�s �J TANK ID S <br /> TANK SIZEu FUEL TYPE /IC.C�7' pDi.� <br /> I 11 tqe K fifekKo-we <br /> iL. GENERAL SITE HIS Y V <br /> as <br /> Is permit current? Yes No Permit # - Facility Status Code Doe.Soil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) U XK"; Type of Tank Steel Fbrgt Sngl Dual <br /> LII. TANK HISTORY <br /> Was Tank tested? Yes No Fatted precision test 1 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? Y"II 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 /> :V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water 41 b Ref/Yes 6 Average Annual Precipitation A= 14 10-25 <br /> On-Site Well(s) Yes No Number 6 Type Irr Dam Pub <br /> 5 Score S Score S Score <br /> ,Distance to WeLL(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if O if 0 if <br /> R condition R condition R condition <br /> V. Site Feature • Leaching Potential Analysis E is met E is net E is met <br /> IMiniimm Depth to groundwater from the Soil Sample (feet)"— >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 /> lMan-Made conduits which increase vertical migration <br /> of Leachate (i.e., septic system, water wells, ponds) None Unknown Present <br /> 'Unique site features: Recharge area, coarse soil, nearby wells. At least More then <br /> xxxxxx Note q one one <br /> COLUMN TOTALS»>TOTAL POINTS ( li + + ) } <br /> Sample Result: IS 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 S-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. 9A\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> 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 u5 ft., do riot use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for STX3E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> MME <br /> V1. STAFF 2ECONDATION/CONCLUSION J LWW �./IGL�� 'v/✓ <br /> 1. Are SIX 8 E or TPH Concentrations > Allowable Levels *Yes No 4 -�Slee C`flyLO�JQQ"�}Q�fiUj <br /> 2. Recommend SiteClosure Yes No If Yes, Refer to Site Mitigation for Evaluation of Q¢/E,fGc �li' <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 o� hY <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 =,� <br />