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SAN JOAQUIN COL,..rPUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALT.,..WJISION DATE / / <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> . OF FACILITY 'e 42,NSr9'h � nBOI �p(,S 7,41 G* SWEEPS CODE <br /> 14 <br /> ADDRESS 500 LAD T�• T�/ G TANK ID # ---------T <br /> TANK SIZE —13',$D 0 FUEL TYPE <br /> Doc.Sol <br /> o '-i l/GW Cont Yes �. <br /> it. GENERAL SITE HISTORY � <br /> Is permit current? Yes No Permit # <br /> - Facility Status Code ( N0 <br /> 2 Age of Tanks(if available) �� TYpe of Tank Steel FbrgL Sn9L Dual <br /> Number of Tanks at facility J <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No If yes, give <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done uMer inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G 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 /> ived Yes Water Ref/Year 04j ; <br /> Average Annual Precipitation A= 14 10-25 <br /> Soil Samples ReceNo Depth to Ground <br /> On-Site WeLI(s) Yes No Numbelr 8 Type Irr Dom Ptd S Score S Score S Score <br /> Well Distance to s) from Tank Ito t; Q—f t; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 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 /> Mini mum Depth to groundwater from the Soil Sample (feet) �0.. <br /> >100 <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> None Unknown Present <br /> xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Average Annual Precipitation (inches) <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 /> bxjj�er a / � C Y _ <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 /> T3 ® �' = ND <br /> B T X E B T X <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 I <br /> Sample Result: <br /> GASOLINE 1000 100 10 <br /> 3` [J" ♦ `QPH MAXIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL 10,000 1000 100 <br /> FOOTNOTES: �V • if documented soil and/or ground water contamination is present, do not complete the hin <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 TPH concentration of 10 ppm((gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION NDICS U�jS Z,"Vz cC 1M <br /> USr /+Isaoo'atlU�LE� n� ' <br /> 1. Are BTX 8 E or TPH Concentrations > Allo able Levels 'Yes Nc C �p L� <br /> 2. Recommend Site Closure Yes No -if Yes, Refer to site Mitigation for Evaluation !C' (°.(jyL`t l� <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR v" - (JX <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YESy NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / � D TE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR �^ Y y�y-� ${�� <br /> EH 23 80 (UGTWKSHT)\5/90 Q, Q C. 1 (}yv 'L(NYI.>�<? .q�-� M t g E 7 D; Qe I �T�3 F) T-#TIICl /Y <br /> 0 K4 n-C& <br />