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SAN JOAQUIN CWZY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL-PPAIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY Tf <br /> iN SWEEPS CODE <br /> uA fo / <br /> ADDRESS ! IIH TANK ID # QsJsb �Z <br /> TANK SIZE S FUEL TYPE <br /> V . GENERAL SITE XI DRY <br /> K �"uedisc�oer� <br /> •as <br /> Is permit current? Yes No Permit # - Facility qtigtus Code Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) �� Z Type of Tank Steel Fbrgl Sngl Oual <br /> III. TANK HISTORY <br /> Was Tank tested?I Yes N Failed precision test ? Yes No If yes, give date(s) <br /> Was a repair made to the tank system) Yes N If yes, what was repaired? <br /> Was repair done under inspection'+ Yes N Were soil samples analyzed Ye No TX TPH-G TPH-D Pb <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 Receiv Yes Depth to Ground Water -l� Ref/Year 186 ; Average Annual Precipitation A= 14 10-25 <br /> On-Site Wells) Yes No Number & Type Irr Dam Pub <br /> S Score S Score S Score <br /> Distance to Wells) from Tank ft; ft; ft 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 - Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) _ IO. >100 51-100 s 25.50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) /O 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 <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <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 /> ND B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-%-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: ��M - - GASOLINE 1000 100 10 <br /> Al I1 MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPN DIESEL 10,000 1000 100 <br /> FOOTNOTES: <br /> ***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 BTX&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closureesu No •If Yes, Refer to Site Mitigation for Evaluation <br /> I. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISO /SENIOR <br /> CONCUR,tWiTH STAFF RECOMMENDATION FOR CLOSURE I YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> is <br /> NAME OF <br /> EVALUATOR r <br /> EH 23 80 (UGTWKSHT)\5%90 i <br />