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SAN JOAQUIN Cdkft-► PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA127-06 I VISION r <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> INANE OF FACILITYI I AS 14u SWEEPS CODE 3/D <br /> IADORESS O 8' c' S'' C ff./.. TANK IO # - Q _ 1114 <br /> TANK S12 FUEL TYPE a Y1JK� V <br /> it. GENERAL SITE HI ORY <br /> !Yf <br /> Is permit current? Yes No Permit # - Facility Status CodeDoc.Soil/GW Cont Yes <br /> Number of of Tanks at facility) Age of Tanks(if available) (.fes Type of Tank Steel Fbrgt SngL Dual <br /> .:. TANK HISTORY <br /> 'Jas Tank tested? Yes No Failed precision test ? Yes No If yes, give date(s) <br /> vas 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 I TPH-G TPN-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 Average Annual Precipitation A= 14 1(3-25 <br /> On-Site WeIL(s) Yes No Number,8 Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts 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) 10,(w >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) 10 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 Cl Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> I <br /> COLUMN TOTALS»>TOTAL POINTS I D a ♦ _ AL <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=.Oast x = <br /> �� <br /> 0,A5 fI <br /> -' • ` , MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 6 50 50 50 .3 .3 1. i. NA1,3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> =% TPH MAXIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL 10,000 1000 100 <br /> FOOTNOTES: ...If documented soil and/or ground water contamination is present, do not carp etc t e 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 /> VI. STAFF RECOMMENDATION/CONCLUSION 11rO J.� Y ,t,' / n/1/1.,� . /i„ = AJDI-10 <br /> 1. Are BTX 8 E or TPH Concentrations > Allow Le Levels +Yes No ��/ (J <br /> 2. Recommend Site Closure Yes No •If Yes, Refer to Site Mitigation for Evaluation (Lt4.N/'L}on@a/' <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 <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />