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SAN JOAQUIN COU. PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL'.- .SION <br /> !' UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> Z.> <br /> (NAME OF FACILITY _/ TANKID <br /> DE /7r�' 9 <br /> ADDRESS 00 /�� v/ �.l / _ <br /> /� �GYT• 3-7 <br /> TANK SIZE �A.j� FUEL TYPE W/U <br /> 11. GENERAL SITE HISTORY <br /> •�� <br /> Is permit current? Yes No Permit # - Facility Status Code O I Doc.Soil/GW ConC YesNo <br /> NIrnber of Tanks at facility G, Age of Tanks(if available) Type of Tank Steel Fbrgl SngL Dual <br /> I!1. TANK HISTORY <br /> Was Tank tested?2toth)e <br /> Etank <br /> !syys!tm?jYnesNo <br /> test 7 Yes No If yes, give date(s) <br /> Was a repair madIf yes, what was repaired? <br /> Was repair done under inspection? YesL_jWere soil samples analyzed? Yes No BTXE TPN-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 No Depth to Ground Yater Ref/Year 5(- Average Annual Precipitation A= 14 10-25 <br /> Or-Site Welt(s) Yes No Number & Type Irr Dom Pub <br /> 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 1f 0 if <br /> R condition R condition R condition <br /> IV. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feeU /6 >100 51-100 O 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration o7 <br /> of leachate (i.e., septic systems, water wells, ponds) None l Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby welts. q At least More than <br /> %x)t%XX None \ me one <br /> COLUMN TOTALS»>TOTAL POINTS + 3L + <br /> SampL Result- (B T % OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> L.0. •.1OSAT rl x;.005 ' <br /> •.roSP/�� B T X E B T X E <br /> X' tf./ ooSAB9 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 /> /i,P i LSn� fPq�f MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> nl.p.� 6*P1n.TPH-0 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 sail 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 TPN concentration of 10 ppn rgasoline) or 100 ppm (diesel). <br /> VI. STAFF IECOMMENDATION/CONCLUSION e _ /,�A <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels A/ — /7n/ <br /> 'Yes No / <br /> Ti.t <br /> e CLosu7�//-� <br /> 2. Recommend SitrelYes NoI *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 L,11101 REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE L TER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />