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SAN JOAOUIN CeY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAM DIVISION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE b <br /> INANE Of FACILITY EEPS CODE <br /> ADDRESS TANK ID # <br /> TANK SIZE Q 61 FUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> H* <br /> FIs permit current? Yes No Permit # - Facility Status Code DOc.SOiL/GW Cont Yes NO <br /> Number of Tanks at facility Age of Tanks(if available)1444 <br /> // Type of Tank Steel FbrgL Sngl Dual <br /> III. TANK HISTORY /!L` <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 /> .I Was repair done under inspection? Yes No Were soil samples analyzed? YesjV INo BT XE TPH-G TPH-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 WaterlRef/Year verage Annual Precipitation A= 14 10-25On-Site Wells) Yes No Numbrs Score s Score s Score <br /> Distance to Well(s> from Tank 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 AnalysisE is met E is met E is met <br /> IMinimm Depth to groundwater from the Soil Sample (feet) >100 51-100 Z5-50\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 /> Man-Made conduits which increase vertical migration <br /> jof leachate (i.e., septic systems, water wells, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> I COLUMN TOTALS»>TOTAL POINTS i ` o - �b <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> I B T % E B T X E <br /> N•O 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 /> i MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> •O 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 an 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 /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrate > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation <br /> V:I. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES L NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATTE1 CLOSURE LETTER MAILED <br /> NAME Of ) <br /> EVALUATOR l7�/ <br /> EH 23 80 (UGTWKSHT)\5/90 <br />