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SAN JOAQUIN c WjY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE 'i DIVISION TG <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION \J DATE T ` — <br /> l. <br /> SWEEPS LODE <br /> NAME OF FACILITTANK ID # _ 39 <br /> ADDRESS <br /> TANK SIZE FUEL TYPE <br /> ii. GENERAL SITE HISTORY *** <br /> Is permit eurrent7 Yes No Permit # - Facility status Code Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility <br /> Age of Tanks(if available) I Type of Tank Steel Fbrglj 1"-11 Dual <br /> Ill. TANK HISTORY <br /> ision lest ? Yes No If yes, give date(s) <br /> Was Tank tested? Yes No Failed prec <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BIKE TPH-G TPH-D Pb/E08 <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 T irr Dan Pub <br /> On-Site Wells) Yes No Type S Score S Score s Score <br /> Distance to Wells) from Tank ft; ft; ft C 10 pts LO ifpts CO if <br /> pts <br /> o 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) <br /> >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> 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 None Unknown Present <br /> of leachate (i.e., septic systems, water wells, ponds) <br /> At Least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None one one <br /> + _ ) <br /> COLUMN TOTALS>»TOTAL POINTS + <br /> 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 B T XE <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> GASOLINE 1000 100 10 <br /> Sample Result: <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL 10,000 1000 100 <br /> TPH <br /> ***If documented soil and/or ground water contamination is present, do not complete the Leaching p <br /> FOOTNOTES: otential <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 TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BT% 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 MAILE1 . <br /> D <br /> NAME OF <br /> EVALUATOR ' <br /> EH 23 80 (UGTWKSHT)\5/90 <br />