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SAN JOAGUIN COUNTY " 3LIC HEALTH SERVICES/ENVIRONMENTAL HEALTH D" SIGN DATE <br /> UGS SHEET FOR SITE CLOSURE EVALUATION <br /> SWEEPS CODE <br /> NAME OF FACILITY <br /> TANK ID # <br /> ,ADDRESS <br /> TANK SIZE FUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit # Facility Status Code Doc.Soil/Gw Cont Yes <br /> NuObnI er of Tanks at facility Age of Tanks(if available) Type of Tank Steel FSngl Dual No <br /> Ei <br /> 111. TANK HISTORY <br /> —71 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 If yes, what was repaired? <br /> Was repair done under inspection? Yes Nol were soil sa0ples analyzed? Yes No BTXE TPH-GI TPH-O 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 Ref/Year <br /> Average Annual Precipitation A= 14 10-25 <br /> Cn-Site WeLL(s) Yes No Number 3 Type Irr Dom Pub <br /> 5 Score 5 Score S Score <br /> Distance to WeLI(s) from Tank ft; ft; ft C 10 pts C 9 pts C5tpts <br /> 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis <br /> E is met E is met E is met <br /> >100 51-100 25-50\1 <br /> IMinim , Depth to groundwater from the Soil Sanple (feet) <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> None UnknownPre6se4XXXXXX <10 9 10-2; nt <br /> Average Annual Precipitation (inches) <br /> XXxxxxX 2 - 0\2 <br /> Man-.Made conduits which increase vertical migration None 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 one one <br /> 4 <br /> COLUMN 70TALS»>TOTAL POINTS y <br /> Sample Result: (3 T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 • 48 pis 40 pts or less <br /> S T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: <br /> GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) 100 <br /> TPH DIESEL 10,000 1000 <br /> FCOTNO7ES: "'If docurented soil and/or ground water cantaminati an is present, do not conplete the leeching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> \9 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., da not use table. <br /> \2 It precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are no[ applicable at a TPX concentration of 10 ppo (gasoline) or 100 ppo (diesel). <br /> VL STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are 3TX b E or TPH Concentration > Allowable Levels -Yes No <br /> 2. Recomend Site ClosureYes No •If Yes, Refer to site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONC'R WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES HO <br /> DATE REFERRED / / DATE CLOSURE LETTER NAILED / / <br /> NAME Of <br /> EVALUATOR <br /> EH 23 30 (UGTWKSHT)\5/90 <br />