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SAN JOAQUIN COUNTY IC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIV'SION <br /> [, UGST SHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY i 1 1� "�� .�. . ,--/j j SWEEPS CODE 7 [w <br /> ADDRESS - ��( - "'�-�- 1- TANK ID <br /> TANK SIZE S%i;�i FUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit q Facility Status Code Ul; Doc.Soit/GW Cont Yes No <br /> Number of Tanks at facility / Age of Tanks(if available)I� .� �` (Type of TankISteell lFbrgll Sngll Dustl l <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No ?( Failed precision test 7 Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No -X If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BT%E -H-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 /> Soil Samples Received Yes NoDepth to Ground Vater '�j Ref/Year L� Average Annual Precipitation A= 14 10-25 <br /> On-Site Wells) Yes No X Nuaber & Type Irr Dan Pub <br /> S Score S Score S Score <br /> Distance to Well(s) from Tank ft; ft; ftC 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 /> Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 67 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) nom' None unknown 1Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS>»TOTAL POINTS ��� + <br /> Sample Result: (S T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> i <br /> 03 (- X, ,D55 g T % E B T % E <br /> C)l C) 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 /> NAXIMUN ALLOWABLE TPH LEVELS (PPM) <br /> TPH 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 preeipitati on is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION % q/ /e 4 J = a1 7 <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels TYeF No <br /> 2. Recommend Site Closure Yes No X -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 ` /� / 2 DATE CLOSURE LETTER NAILED <br /> NAME <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />