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SAN JOAQUIN CCS_ PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL,.wWIVISION <br /> I' UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> HANE OF FACILITY rt.. SWEEPS CODEI -10063 <br /> ADDRESS 313 a <br /> :z> <br /> J / - <br /> TX,5r 7" TANK ID 41 <br /> TANK SIZE / I O I FUEL TYPE W�5 <br /> 11. GENERAL SITE HISTORY <br /> its permit current? Yes No xPermit Facility Status Code IDoc.Soi l/GW Cont Yes No <br /> !Munber of Tanks at facility ' Age of Tanks(if available) Type of TenklSteel IFbrgL ISngL Dual <br /> [11. TANK HISTORY rel <br /> IWas Tank tested? Yes Na Failed precision test ? Yes No IIf yes, give date(s) <br /> 'Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> ;,4as repair done under inspection) Yes NoI Were soil samples ana lyzed?IYes No BTXEI ITPH-G TPH-D Pb/EDB <br /> `ype of failure/discharge) catastrophic (long-term leakage) )overfill )unknown) other: <br /> iV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water 46 Ref/Year)8'� Average Annual Precipitation A- 14 10-25 <br /> On-Site WeLL(s) Yes No Number & Type Irr Dam Publ <br /> 5 Scare S Scare S Scare <br /> Distance to Well(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 'c is met E is met <br /> Minirmm Depth to groundwater from the Soil Sample (feet) ,g s I >100 I I51-100 I 125-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) / I None I Unknown Present <br /> !Average Annual Precipitation (inches) xxxxxxl <10 9 110-25 Ixxx;o= 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, Ponds) None Unknown Present <br /> (Unique site features: Recharge area, coarse sail, nearby wells. I Cj At least !lore then <br /> xxxxxx Nara e on <br /> 1 I ane <br /> COLUMN TOTALS»>TOTAL POINTS / 01 + I' u { + I <br /> Samole Result. (B T X OR E) RANGE OF TOTAL POINTS 49 pis or more 41 - 48 pts 4SpotentiaL <br /> rK1os/ X = .-k1 <br /> 4 T X E B T X <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 SO .3 .3 1. 1. <br /> Kle Regult.�0 7 pN GASOLINE 1000 100 <br /> MAXIM(Rl ALLOWABLE TPN LEVELS (PPM) <br /> TPH D DIESEL 10,000 1000 <br /> .FOOTNOTES: ^"If documented soil and/or ground water Contamination is present, do not coapt are t Leachi <br /> analysis. (i.e., site is currently at UGT Contamination List for soil or gro <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 > 46 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable�aat a TPN concentration of 10 ppm (gasoline) or 100 Pon: (diesel). <br /> VI. STAFF RECO)MENOATION/CONCLUSION IK a t'(,t& 6r �, AJ{•' /v l �d D�y � a. Zr'n C- ' `/`/*� <br /> 1. Are BTX & E or TPH Concentration > Allowable Levels 'Yes No <br /> 2. Recommend Site Closure Yea No E-If Yes, Refer to site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR E(UGTWKSHT)\5/90 <br /> ECOMMENDATION FOR CLOSUREIYES NOI IREFERREO TO SITE MITIGATION FOR EVALUATION YES( NO <br /> TE RE / / S (DATE CLOSURE LETTER MAILED <br /> OORI 2� <br /> F <br />