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SAN JOAQUIN CD,,, PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALtWAVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY ETANK <br /> CODE <br /> ADDRESS bp Y- q. V\I,?kXir^ D 0 <br /> TANK SIZE Z K 1, p FUEL TYPE 3q- CIO 1,511D <br /> 11. GENERAL SITE HISTORY <br /> •tr <br /> Is panni[ current? Yes Nol>,- Permit p - Facility Status Code DOc.Scll/GW Cont Yes No <br /> Number of Tanks at facility 2 Age of Tanks(if available) lLl1 � Type of Tank Steel FbrgL Sngl Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? Yes No Failed preciotestYes No If yes, give d;other: <br /> Was a repair made to the tank system? Yes yes, what was repaired>Was repair done under inspection? Yes Noil samples analyzed? Yes Y- No TPH-G � TPH-D XPb/EDB <br /> Type of failure/discharge catastrophic eakage overfill unknown <br /> V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes )c No Depth to Ground Water Ref/Year . Iirq; 5 Average Annual Precipitation A= 14 10-25 <br /> On-Site Wells) Yes No X Number 8 Type Irr Dom Pub v <br /> Distance to WeIL(s) from Tank ft; ft; - S Score S ScorTe Score <br /> ft C 10 pts C 9pt5 pts <br /> 0 if 0 ifif <br /> R condition R condcondition <br /> V. Site Feature - Leaching Potential Analysis ,. E is met E ismis met <br /> Minimum Depth to groundwater from the Soil SempLe (feet) >100 51-100 S' 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) 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 Unknown _5 Present <br /> Unique site features: Recharge area, coarse soil., nearby wells. At least More than <br /> xxxxxx None 9, one one <br /> COLUMN TOTALS>>>TOTAL POINTS + + _ <br /> Sampte Result: (B T XX�OR E) RANGE OF TOTAL POINTS 49 pts or more .41 - 48 pts 40 pts or less <br /> LW to, "I `-J B T X E 1 8 T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 - 100 10 <br /> '�� My�k.a MAXIMGM ALLOWABLE TPH LEVELS (PPM) <br /> d- TPH (a DIESEL 10,000 1000100 <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 BTX3E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> . STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX b E or TPH Concentrations > ALLowable Levels [Yes No <br /> 2. Recommend Site Closure Yes No •If Yes, Refer to Site Mitigation for Evaluation <br /> I. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR,tWITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> HEVALUATOR <br /> / / G DATE C OS <br /> LETTER MAILED <br /> L� <br /> EH 23 80 (UGTWKSHT)\5/90 <br />