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SAN JOAQUIN e,,,dTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H6,00rl DIVISION / 7 <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> 16 3 <br /> NAME OF FACILITY R�Sj ft n^^ SWEEPS CODE , <br /> ADDRESS b500 f. Br dWOQr)l' , LOL ��C> TANK ID #0301- 0515-(062 15-(062 <br /> TANK SIZE I Z I auD FUEL TYPE M J� <br /> 11. GENERAL SITE HISTORY *** <br /> Is permit current? Yes No Permit # - Facility Status Cade Doe.Soil/GW Lont Yes No <br /> Number of Tanks at facility ' Age of Tanks(if available) Y Type of Tank Steel /\ Fbrgl Sngl Dual <br /> M <br /> III. TANK HISTORY <br /> MW <br /> Yes No Failed precision test 7 Yes Na If yes, give date(s) <br /> e to the tank system? Yes No If yes, what was repaired? <br /> under inspection? Yes No k Were soil samples analyzed? Yes No BTXE TPH-G TPN-D Pb/EDB <br /> 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 Receivedno <br /> Ground Water13S Ref/Year ;qA Average Annual Precipitation A= 14 10-25 <br /> On-Site Wells) Yes Irr ' Dom Pub S Score S Score S Score <br /> Distance to WeII(s) fft; ft; it C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if O if <br /> R condition R condition R condition <br /> V. Site Feature - tial Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) >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 None Unknown 5 Present <br /> of leachate (i.e., septic systems, water wells, ponds) <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None �f one one <br /> COLUMN TOTALS>>>TOTAL POINTS Lo `� S = 4 2 <br /> Sample Result-. (B T X7ORE) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pta> 40 pts or less <br /> N � 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 /> Sample Result: GASOLINE 1000 100 10 <br /> �J <br /> \'�) TPH MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 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, score0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION s6f_Lpn1R. 16 M-3 -�- <br /> &J LA* 1 �� l — S- 2 MV. <br /> V-0 <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels *Yes No L"I, , <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 /> CORCUR WITH STAFF RECOMMENDATION FOR CLOSURE YE 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 />