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t - <br /> SAN JOAQUIN r0,4I PC HEALTH SERVICES/ENVIRONMENTAL HEALTH 01 N DATE <br /> UGST SHEET FOR SITE CLOSURE EVALUATION 4k I <br /> SWEEPS CODE <br /> NAME OF FACILITY 2 Zl� TANK ID it - ZfOf1atjo <br /> ADDRE=TS1 Z <br /> TANS: SIZE e,;' FUEL TYPE <br /> IT. GERIiRAL SITE HISTORY <br /> Facility Status Code Doc.$oil/GW Cont Yes No <br /> is permit current? Yes No Permit # Type of Tank Steel Fbrgl Sngl Dual <br /> Nu~�c^_r of Tanks at facility <br /> Age of TaNus([f available) <br /> (11. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No if yes, give dates) / / <br /> Was a repair made to the tank system? Yes No I# yts, what was repaired? <br /> Was repair dans under inspection? Yes No Were sail samples analyzed? Yes No BT E! TPR-G 7PH-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 /> Soil Samples Received Yes No Depth to Ground Water of/Year 96 7 <br /> Average Annual Precipitation Ay 14 10-25 <br /> on-Site Well(s) Yes No Number & Type Irr Don Pub S Score <br /> S Score S Score is <br /> ft; ft; �ft C 10 pts C 9 pts C 5fp <br /> Distance to Wells) from Tank 0 if 0 it <br /> R condition R condition R isition <br /> V. Site Feature - Leaching Potential Analysis <br /> E is met E is met E <br /> >100 51-100 25-50\1 <br /> Minimum Depth to groundwater from the Soil Sample (feet) <br /> None Unknown Present <br /> Fractures in subsurface (applies to foothills or mountain areas) 26.40\2 <br /> Average Annual Precipitation (inches) <br /> xxxxxx <10 9 10-25 xxxxxxx <br /> Man-Made conduits which increase vertical migration None 1 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 ane one <br /> COLUMN TOTALS»)-TOTAL POINTS <br /> Sample Result• (g T X OR E) t� RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts\ 40 pts or less <br /> ��.od9 Pk) bE,.oaSP, B T X E 8 T X E <br /> T,ov5 AP - -0- <br /> 7Ca.PJtspp-\ MAxIM X ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. � <br /> GASOLINE 1000 100 10 <br /> Sample Result: <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) 1000 100 <br /> ,� J00 r TPH-D <br /> DIESEL 10,000 <br /> FOOTNOTES: <br /> ***If documented sail and/or ground water contamination is present, da 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 ape at a TPN concentration of 10 perm (gasoline) or 100 ppm (diesel). <br /> applicable <br /> / 0 <br /> VI. STAFF RECOMMENDATION/CONCLUSTOM <br /> 1. Are BTX & E or TPH Concentrations > Allowable levels *Yes Ho <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 /> FEVALIUATOR <br /> H STAFF RECCMMENDA7lON FOR CLOSURE TES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> RED / / DATE CLOSURE LETTER MAILED <br /> EH 23 30 (UGTWKSHT)\5/90 <br />