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SAN JOAOUIN COUNTY -" LIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION DATE F-a If -q�- <br /> UGST ;SHEET FOR SITE CLOSURE EVALUATION <br /> I' "o' SWEE 5 CODE o'1 37•+'� <br /> NAME OF FACILITY NL/S / ('� TANK ID 0 yI - r71 -37� —d/ <br /> ADDRESS �y S. NU/J� <br /> TANK SIZE /UpUp - FUEL TYPE Oleo r <br /> •�f <br /> it. GENERAL SITE HISTORY <br /> is permit current? Yes No Permit $ <br /> Facility Status Code 9' 7 <br /> Dx.Soil/GW Cont Yes No <br /> Number of Tanks at facility <br /> Aye of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test Yes V No if yes, give dates) <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 BT%E TPX-G TPX-D Pb/ B <br /> ED <br /> Type of failure/discharge catastrophic long-term Leakage _.-4;1 1 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 Vater j,} Ret/Year <br /> y�' Average Annual Precipitation A= 14 10-25 <br /> On-Site WeLL(s) Yes No Number i Type Irr Das Pub S Score S Score S Score <br /> Distance to Wells) from Tank If ft; ft; it C 10 pts C pis CO If 0 if 0 <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis •? E is met E is met E is met <br /> 25-50\1 <br /> Minimum Depth to groundwater from the Soil Sample (feet) �->10O 51-100 <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 ID None Unknown Present <br /> of leachate (i.e., septic systems, water wells, ponds) <br /> Unique site features: Recharge area, coarse soil, nearby wells. G 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 /> 8 T X E BT X E <br /> "f"= •d y' MAXIMA( ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. XA%3 1 <br /> Sanple_Result: , <br /> GASOLINE 1000 100 10 J <br /> 7Yo //"' MAXIMUM ALLOWABL00 1000 <br /> E TPH LEVELS (PPN) <br /> TPH DIESEL 10,0 100 <br /> FOOTNOTES: •`•If documented soil and/or ground water contamination is present, do not complete the leach LYg-poCential <br /> aria lysis. (i.e., site is currently on UGT Contamination List for soil or gromd water) <br /> —_" <br /> V if depth is > 5-�—and<2"t., score 0-poinl_3:-Tf;depth <=5 ft., do not use table. <br /> \2 If precipitation is > 0 inches, store 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentrati of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allow Le 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 CLOSUR LETTER MAILLE��D <br /> NAME Of - 1) <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />