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Ti <br />Tf <br />11 <br />SAN JOAQUIN #L MTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE98 DIVISION <br />1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE 9 <br />NAME OF fACILITY ! Yl 8 �/ SWEEPS CODE z� <br />,ADDRESS Ra3 D v4 <br />1p� s QG e�..�� TANK ID #3q - CJ C�rJ..Da <br />TANK SIZEI /040DD (FUEL TYPEI 46VQv�— _i <br />(1. GENERAL SITE HISTORY �r <br />Is permit current? Yes No Permit # - Facility Status Code DOC.Spil/GW Cont Yes No <br />'Number of Tanks at facility Age of Tanks(if available) Type of TankISteetl Fbrgl Sngl Dual <br />III. TANK HISTORY <br />:Was Tank tested? <br />Yes <br />NO REFERRED TO SITE MITIGATION FOR EVALUATION <br />No <br />Failed precision test ? <br />Yes <br />Ref/Year <br />No <br />If yes, give date(s) <br />A= <br />'Was a repair made to the tank system? <br />Yes <br />No <br />Yes <br />If yes, what was repaired? <br />No <br />«as repair done under inspection? <br />Yes <br />No <br />Were soil samples analyzed? Yes <br />No <br />BTXE <br />TPH-G <br />TPH-D <br />Pb/E08 <br />!,Type of failure/discharge <br />catastrophic <br />long-term leakage <br />overfiLLl <br />unknown <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received <br />Yes <br />NO REFERRED TO SITE MITIGATION FOR EVALUATION <br />No <br />Depth to Ground Water <br />Ref/Year <br />'DATE REFERRED <br />Average Annual Precipitation <br />A= <br />14 <br />10-25 <br />0 -Site WeLI(s) <br />Yes <br />No <br />Number & Type <br />Irr <br />Dan <br />Pub <br />S <br />Score <br />S <br />Score <br />S <br />Score <br />--.Ostance to Well(s> from Tank <br />ft; ft; ft <br />C <br />0 <br />R <br />10 pts <br />if <br />condition <br />C <br />0 <br />R <br />9 pts <br />if <br />condition <br />C <br />0 <br />R <br />5 pts <br />if <br />condition <br />!V. Site Feature - Leaching Potential Analysis <br />E <br />is met <br />E <br />is met <br />E <br />is met <br />;Minimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />51-100 <br />25-50\1 <br />,Fractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />Present <br />,Average Annual Precipitation (inches) <br />XXXXXx <br />00 <br />9 <br />10-25 <br />x,xxxxx <br />26-40\2 <br />;Man -Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />Present <br />!Unipue site features: Recharge area, coarse soil, nearby wells. <br />At least <br />More than <br />xxxxxx <br />Hare <br />one <br />one <br />�► �+ �1� �1' r?•r �( <br />'41V <br />Taw. /7 �I ,Vu V�LLll <br />iTt�F = D SOL MN TOTALS»>TOTAL POINTS <br />r <br />' amply] Repsult: (B T X OR E) K� RANGE OF TOTAL POINTS <br />49 pts or more <br />41 - 48 pts <br />40 pts or less <br />k '{TJ' •TIL X0-7 T=jOlb <br />/Aim <br />B T X E <br />B T % E <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />1I 50 50 50 <br />.3 .3 1. 1. <br />NA\3 <br />a Result: <br />S <br />GASOLINE <br />1000 <br />100 <br />10 <br />P-Samo <br />a IV p <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />10,000 <br />1000 <br />100 <br />-Sfu D TPH <br />DIESEL <br />FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the le <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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />'/I. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br />i 2. Recommend Site Closure Yes No k If Yes, Refer to Site Mitigation for Evaluati <br />REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE <br />YES <br />NO REFERRED TO SITE MITIGATION FOR EVALUATION <br />YES <br />NO <br />'DATE REFERRED <br />/ / <br />DATE CLOSURE LETTER MAI LEDI / / <br />NAME OF <br />EVALUATOR <br />EN 23 80 (UGTWKSHT)\5/90 <br />