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SAN JOAQUINCOU*LIC HEALTH SERVICES/ENVIRONMENTAL HEALTI SIGN —/ r <br /> I. UCS RKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY SWEEPS CODE <br /> �j f� TANK ID it - � � y �j <br /> ADDRESS /V , ICJ <br /> TANK SIZE ! D(� FUEL TYPE <br /> 11. GENERAL SITE HISTORY rr* <br /> Is peEof <br /> rrent? Yes No Permit Facility Status Code --.Soil/GW Cont Yes No <br /> Numbenks at facility Age of Tanks(if available)[ <br /> Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 Yes No If yes, give date($) <br /> was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were Soil samples analyzed? Yes No STXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill unknrnrn other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No :eptlto Ground Water Ref/Year Average Annual Precipitation A= 14 10-25 <br /> On-Site UeLL(s) Yes No Num & Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to WeLL(S) from Tank ft; #t; ft C 10 pts C 9 pts C 5 pts <br /> - 0 if 0 if O if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching PatentiaL Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet)l�G�j� >100 51-100 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 <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 /> Sale Result: B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> I -�e Resu� 1A iU B 7 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 /> 1 <br /> Sample Result: 1 , bGASOLINE 1000 100 10 <br /> - Lu MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> �1 TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the Lea. tng 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, scare 0 points. <br /> \3 Levels for 9TX&E are not applicable at a TPM concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TAH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes 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 NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED I / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />