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SAN JOAQUIN CC f PUBLIC HEALTH SERVICES/ENVIRONMENTAL NEA DIVISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE 3 g <br /> NAME OF FACILITY SWEEPS CODE <br /> ADDRESS /D A� TANK ID <br /> TANK SIZE FUEL TYPE 7�s <br /> .1. GENERAL SITE HIS Y <br /> »t <br /> Is permit current? Yes No Permit 0 - Facility Status Code Ooc.SOiL/GW Cont Yes No <br /> Number of Tanks at facility Lt <br /> Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No I X <br /> Failed precision test 7 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 saaples ana lyzed7 Yes No STXE TPH-GTPH-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 ARALYSIS) <br /> Soil Samples deceived Yes No Depth to Ground Water 4� Ref/Year Average Annual Precipitation A-114 10-25 <br /> �On-Site WeIL(s) Yes No Number & Type Irr Dao Pub , <br /> S Score S Score S Scar <br /> Distance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 ptse <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis =A E is met E is mwt E is met <br /> Mininwm Depth to groundwater trap the Soil Sanple (feeU >100 51-100 25-50\l <br /> lFractures in subsurface (app(ies to foothills or mountain areas) f.." None I 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 Unkmwr% Present <br /> 'Unique site features: Recharge area, coarse soil, nearby wells. At least .� More than <br /> XXXXXX None �' one ane <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 /> Saaple Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: "'If documented soil ardor ground water contamination is present, do not complete the Leaching potential <br /> analysis. (i.e., site is currently on LOT 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 (diienet). <br /> VI. STAF- 2ECO41ENDATION/CONCLUSION !t-�y�>�y��1J a �(� L.l�b - <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels `Yes No J`��(�V�-4^'S`f/M�^n,'',_-,,/.,V.,,�u <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation G�HL�-� <br /> -t�Q c� e�vatGoy`drt� <br /> 'ill. REVIEW EVALUATION - TO BE COMPLETED BY A ERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES Hal I <br /> DATE REFERRED / / DATE CLOSURE LETTER NAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 , (UGTWKSHT)\5/90- r a <br />