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SAN JOAQUIN C&.. e PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA, IVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE _ <br /> NAME OF FACILITY SWEEPS CODE <br /> r TANK ID # <br /> ADDRESSI 4A <br /> TANK S12E O FUEL TYPE <br /> It. GENERAL SITE HISM� <br /> ,Is permit current? Yes No X <br /> Permit # - Facility Status Code 1 Doc.Soi l/GW Cont Yes No <br /> '.Number of Tanks at facility l Age of Tanks(if available) Type of Tank Steel FbrgL SngL Dual <br /> V <br /> III. 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 IN ECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .Soil Samples Received Yes ' No Depth to Ground Water � 1 Ref/Year 6, +; 93 Average Annual Precipitation A= 14 10-25 <br /> iOn-Site Wells) Yes No Number 8 Type Irr Dan Pub S 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 0 if O 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) >100 51-100 57- 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> Average Annual Precipitation (inches) xx%xxX <10 9 10-25 xxxxxxx 26-40\2 <br /> [Man-Made conduits which increase vertical migration D None Unknown Present <br /> lof leachate (i.e., septic systems, water wells, ponds) <br /> q At least More than <br /> iUnique site features: Recharge area, coarse soil, nearby watts. xxxxxx None / one one <br /> COLUMN TOTALS>>>TOTAL POINTS ja <br /> ;Sample RGsuLt: (B T X OR E) RANGE OF TOTAL POINTS 49 pts40 pts or Less <br /> B TMAXIMUM ALLOWABLE B-T-%-E LEVELS IPPR) 1 50 HA\3 <br /> ,Sample Result: GASOLINE 100010 <br /> hP�G _ / MAXIMUM ALLOWABLE TPN LEVELS (PPM) 100 <br /> 36a TPM DIESEL 10,000 1000 <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. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> 41. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allow ble 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 NOREFERRED 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 />