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SAN JOAQUIN'* PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL�i1VISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE Z <br /> NAME OF FACILITY G/Tr Por LaA SWEEPS CODE <br /> ADDRESS �d �, fjydyp�Typer,� <br /> TANK 1D # <br /> TANK SIZE /Loo FUEK, <br /> II. GENERAL SITE HISTORY ..* <br /> Is permit current? Yes No Permit # - Facility Status Code Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No If yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No HWere 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 ANALYSTS) <br /> Soil Samples Received Yes No Depth to Ground Water 55* Ref/Year $G Average Annual Precipitation A= 14 10-25 <br /> On-Site WeLL(s) Yes No Number & Type Irr Dom Pub S Score S Score S Score <br /> Distance to Wells) 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 /> >100 51-100 25-50\1 <br /> Minimus Depth to groundwater from the Soil Sample (feet) 0 <br /> Fractures in subsurface (applies to foothills or mountain areas) Nane I Unknown Present <br /> Average Annual Precipitation (inches) Xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration None Unknown Present <br /> of leachate (i.e., septic systems, water wells, ponds) <br /> Unique site features: Recharge area, coarse soil, nearby wells. R At Least More than <br /> xxxxxx Nore 2 1 one 2 one <br /> COLUMN TOTALS»>TOTAL POINTS + l + D = J KJ <br /> Sample ResuSt: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T X E <br /> 'y ti MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 11. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> I.eppwI V/)-Cr MAXIMUM ALLOWABLE TPN LEVELS (PPM) DIESEL 10,000 1000 100 <br /> y TPH <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. PP^� ppm (diesel). <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 (gasoline) or 700 <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No �yTB�= /J,0. <br /> 2. Recommend Site Closure Yes I el No *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 0 REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERREDF_/ / DATE CLOSURE LETTER HAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />