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SAN JOAQUIN (..�,(Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEf DIVISION DATE � _ <br /> UGST WORKSHEET FOR SITE CfOSURE EVALUATION I l <br /> 1. <br /> SWEEPS LOGE <br /> NAME OF FACILIT - TANK 10 # n <br /> ADDRESS <br /> TANK SIZE FUEL TYPE <br /> •t• <br /> it. GENERAL SITE HISTORY <br /> Doc.Soi L/GW Cont Yes <br /> Is permit current? Yes No Permit # <br /> Facility Status Cade Na <br /> Number of Tanks at facility <br /> Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> Ill. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 Yes No <br /> If yes, give date(s) <br /> was repaired? <br /> Was a repair made to the tank system? Yes No If yes, what: <br /> Yes No Were soil samples analyzed? Yes No BTXE TPH-G <br /> Was repair done under inspections 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 Water Ref/Year <br /> Average Annual Precipitation A= 14 10.25 <br /> Number 8 Type Irr Dan Pub S Score S Score S Score <br /> On-Site Wells) Yes No C 9 pts <br /> ft; ft; ft c 10 pts C 5 pts <br /> p if <br /> Distance to WeLL(s) from Tank 0 if 0 if <br /> R condition R condition R condition <br /> E is met E is met E is met <br /> V. Site Feature - Leaching Potential Analysis s me is <br /> >100 51-100 <br /> Minimum Depth to groundwater from the Soil Sample (feet) Unknown Present <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> None S <br /> xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Average Annual Precipitation (inches) G <br /> Nan-Made conduits which increase vertical migration <br /> None 1 Unknown Present <br /> of leachate (i.e., septic systems, water wells, Ponds) At least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None <br /> q one one <br /> y C_ <br /> COLUMN TOTALS»>TOTAL POINTS + + <br /> Sample Result: (S T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> B 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 /> GASOLINE 1000 <br /> 100 10 <br /> Sample,Result: MAXIMUM ALLOWABLE TPH LEVELS (PPM) 1000 100 <br /> N DIESEL 10,000 <br /> �_D__JPH - _ P potential <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is resent, do not complete the leaching <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground wafer.) <br /> \1 if depth is > 5 f(. and < 25 I 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 TP <br /> concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No *If Yes, 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 EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED / <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />