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SAN JOAQUIN CC`f PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA01 'JISION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE Q <br /> NAME OF FACILITY SWEEPS CODE <br /> !ADDRESS e TANK ID # - <br /> ITANK SIZE12,M0 Z00a FUEL TYPE <br /> It. GENERAL SITE HISTORY <br /> aaa <br /> Is permit current? Yes No I Apermit # - Facility Status Code Doc.Soil/GW Cont Yes No <br /> jNumber of Tanks at facility ^2— Age of Tanks(if available) Type of Tank steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> ;Was Tank tested? Yes No ed precision test ? Yes No If yes, give date(s) <br /> 'Was a repair made to thek system? Yes No If yes, what was repaired? <br /> Was repair done r inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPN-D Pb/EDB <br /> !Type of fai re/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 /> i <br /> Soil Samples Received Yes I V1No Depth to Ground Water Ref/Tear ci5(6Average Annual Precipitation A= 14 10-25 <br /> IOn-Site Wells) Yes No Number 8 Type Irr Dom Pub <br /> S Score s score S score <br /> 'Distance to Wells) from Tank "s-OL ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if O 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) >100 51-100 S 25-50\1 <br /> (Fractures in subsurface (applies to foothills or mountain areas) None OI 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 S Present <br /> i <br /> !Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS:Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> B T X E 8 T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> I <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 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 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 <br /> 1. Are BTX 8 E or TPN Concentrations > Allowable Levels aYes No <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation <br /> Vt?. 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 11101 1 <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> \ EH 23 80 (UGTWKSHT)\5/90 <br />