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SAN JOAQUIN On.*TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEH_11"DIVISION r� <br /> I, UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE 6 0 <br /> NAME OF FACILITY SWEEPS CODE ``',�`c <br /> ADDRESS ?iy N?i`J EVLGE- epi ^ '✓JD TANK ID # 3-'1 - 15479C <br /> Q 70 <br /> TANK SIZE V FUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> „+v <br /> Is permit current? Yes No Permit # - Facility Status Code Doc.Soi L/GW Cont Yes Na <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgt Sngl Dual <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 inspeetion? Yes No Were soil samples analyzed? Yes No BTXE TPN-G TPH-O 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 10-25 <br /> On-Site Wells) Yes No Number & Type Irr Dom Pub <br /> S Score 5 Scare S Score <br /> Distance to WeLI(s) 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) n 5e� >100 ok <br /> 51-100 25-50\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 q <br /> of leachate (i.e., septic systems, water wells, ponds) more ` Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. 9 At Least More than <br /> xxxxxx None )I One one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 1 - 48'pts 40 pts or less <br /> B <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 /> /• MAXIMUM ALLOWABLE TPX LEVELS (PPM) <br /> ,A 1.D TPN—(ir 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 on UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth c5 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 TPN cencentratian of 10 Ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION �_ Ofmy. -1) 1(2 <br /> p fT6• <br /> 1. Are BTX & E or TPH Concentrations > ALLmabte Levels *Yes No <br /> mm " '— a ! �� <br /> y pmAs'—/ 1 rD <br /> 2. Recommend Site Closure Yes /` No *If Yes, Refer to Site Mitigation for Evaluation Er(3B=n.1.11 ro'� <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SE ION <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES N <br /> DATE REFERRED / / DME CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />