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w SA4 JOAQUIN COUNTYIC HEALTH SERVICES/ENVIRONMENTAL HEALTH O!' " ON <br /> UGST,9SHEET FOR SITE CLOSURE EVALUATION <br /> NAME OF FACILITYGU� / �j(7 SWEEPS CODE <br /> ADOREES� 2 �1 <br /> _ d/// /G�/� TANK ID Y '3 -L— _ O <br /> �rAui; 5;2EI �Q FUEL TYPE ✓ <br /> 1I. rEHERAL SITE HISTORY <br /> Cont No permit current? Yes No Permit tl Facility Status Code Doc.Soil/GW CYes <br /> (Number or Tanks at faciLityll lAge of Tanks0f availabl e)l (Type of Tank Steel Fbrgl Sngl Dual <br /> 111. TANK HISTORY <br /> IrUas Tank ;es ted? Yes No Failed precision test T Yes No If yes, give date(s) <br /> 'lalas 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 BTXE TPN•G TPH-D Pb/ED8 <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br />1:V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/5PLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water Ref/Year ; Z verage Amual Precipitation A= 14 10-25 <br /> On-Site 'Jell(s) Yes No Number 8 Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance ;o WW(s) from Tank ft; ft; 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 /> Minimsm Depth to groundwater from the Soil Sample (feet) ^s i >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 xxzxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic system„ water wells, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. �j At Least More than <br /> xxxxxx None /I one one <br /> COLUMN TOTALS>»TOTAL POINTS ♦ 36 + . 411 <br /> Sample Result: (S T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <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 /> / MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 2^��hS/J• � ' TPH-(y 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, 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 <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels *Yes No >( <br /> 2. Recommend Site ClosurelYesl xlNol <br /> If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENICR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES11,,K01 REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 30 (UGTWKSHT)\5/90 <br />