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SAN JOAQUIN ,CITY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HL_H DIVISION <br /> i UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> y : WEDE <br /> MANEOF:30Z!lm <br /> ADDRESS TANK ID 013 <br /> TANK SI <br /> FUEL TYPE Z); <br /> 11. GENERAL SITE HISTORY ••• <br /> Is permit current? Yes No Permit / 3 - Facility Status Code Doc.Soll/CW Cont Yes No <br /> Nunber of Tanks at faeility Age of Tanks(If available) Type of Tank Steel FbrgII lsrvglr Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Teag No Fal led precision test 7 Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No it yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE 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 Yea TN <br /> Depth to Ground Water Ref/Year ,SS` Average Annual Precipitation A• 14 10-25 <br /> On-Site Wells) Yes Na unber 6 Type Irr Dom Pub <br /> S Score S T.oreSeore <br /> Distance to Well(s) from Tank ft; ft; ft C 10 pts C 5 pts <br /> O If 0 if <br /> R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E Is met <br /> Minimum Depth to groundwater from the Soil Sample (feet)66-/& %Yy >100 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 G, <br /> of leachate (i.e., septic System, water wells, ponds) None Unknown 5 Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one Gonne <br /> COLUMN TOTALS»>TOTAL POINTS '�) • C q <br /> Sade Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> 0 DB T X E B T X E <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 TPH LEVELS (PPM) <br /> N TPN DIESEL 10,000 1000 100 <br /> FOOTNOTES: --*If documented soil arxf/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (1.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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION 4 .� q- 3 S G(z-,- J <br /> 1. Are BTX i E or TPH Concentrations > Allowable Levels •Yes No Q�1Z(�C�oh'e>� <br /> 2. ReeomlNMd Site Closure Yes No •If Tee, Refer to Site Mitigation for Evaluation <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 EV UATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />