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SAN JOAQUIN COUNTYIC HEALTH SERVICES/EHVIRCNME4TAL HEALTH O ON OATS <br /> UGSi SHEET FOR SITE CLOSURE EVALUATION <br /> NAME OF FACILITY O ��� � `G� / //7 _ SWEEPS CODE fj rj� <br /> DDRESSI /� �J Zcxw)S� �.� . �� /� TANK lD if <br /> TANK SIZE rO wo FUEL TYPE <br /> . GENERAL SITE HISTORY •• <br /> ''• rmit current? Yes No Permit Y Facility Status Code D Doo.Soil/GV Cont Yes No <br /> .> Pe <br /> number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual. <br /> . TANK HISTORY <br /> Was Tank tested? les No Failed precision test7 Yes No If e I1 !1 11 <br /> was a repair made to the tank system? Yes No If yes, what was repaired7 <br /> was repair dans under inspection? Yes No cera soil samples analyzed? Yes No BTXE ITPH-C ITP4.0I Pb/EDB <br /> Type of failure/discharge catasiroph is long-term leakage overfill unknown other: <br /> 'l. REMCVAL HISTORY (ATTAC4 INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) _ <br /> Sail Sartples Received Yes No Depth to Ground Vater /SIRef/Year g <br /> 6; Average Amaral Precipitation A• 14 10-25 <br /> On-Site Well(s) Yes No Nunber & Type Irr Dw Pub S Score S Score S Score <br /> Distance to WeLI(s) from Tank 3k."L/ ft; ft; ft CC 10 pts CC 9fpts CC :ifpts <br /> R condition R condition R condition <br /> IV. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minims Depth to groundwater frac the Soil Saiple (feet) <br /> >1CO 51-100 1 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) r <br /> None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which imresse vertical migration None Unknown Present <br /> of leachate (i.e., septic systems, water wells, ponds) <br /> C� At least iNore than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxx� None l OM °^e <br /> COLUMN TOTALS>»TOTAL POINTS jU • + 0 a / <br /> Sartple Result: (8 T X OR E) BARGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T X E <br /> MAXIMUM ALLOVARLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. <br /> Sanple Result.- GASOLINE 1000 100 <br /> 1 iMAI ALLOVABLE TDN LEVELS (PPM) <br /> DIESEL 10,000 <br /> FOOTNOTES: '••if documented soil and/or ground water contamination is present, do not eoaplete 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 3TXBE are not applicable at a TPN concentration of 10 PTs, (gasoline) or 100 ppm (diesel). <br /> VI. STAFF REG WENDATION/CONCLUSION <br /> 1. Are 3TX b E or TPN Concentrations > Allowable Levels •Tes No <br /> 2. Recamand Site Closure Yes No •If Yes, Refer to Site Mitigation for Evaluation <br /> VI% REVIEW EVALUATION - TO SE COMPLETED 3Y A SUPERVISOR/SEMICR <br /> CONCJR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO <br /> REFERRED TO SITE MITIGATION FOR EVALUATION 7E5 HO <br /> CATE REFERRED moi/ / DATE CLOSURE LETTER MAILED <br /> NAMEOF <br /> EVALUATOR Q _ , <br /> `�AIUATCR ✓� <br /> EH 23 30 (UGTWKSHT)\5/90 <br />