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SAN dOAQUIN COULIC HEALTH SERVICES/ENVIRONMENTAL HEALT ION <br /> UGS KSHEET FOR SITE CLOSURE EVALUATION DATE <br /> SWEEPS CODE ,,;3/3 <br /> FACILITY � � // J �/J/ f��/ _� <br /> Sf <br /> / <br /> TANK ID # 1361, ` ! <br /> SIZE �/0 ,9&0 FUEL TYPE <br /> .NERAL SITE HISTORY *** <br /> permit current? Yes No Permit 4 Facility Status Code Doc.Sail/GW Cant Yes No <br /> NAumber of Tanks at facility "! Age of Tanks(if available) Type of Tank Steet Fbrgl Sngl Dual <br /> iI. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes Na 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 were soil samples analyzed? Yes No BTXE TPH-G TPH-0 Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill I 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=114 10-25 <br /> On-Site WeLI(s) Yes No Number & Type Irr Dom Pub S Score S Score S Score <br /> Distance to Wetl(s) from Tank ft; ft; ft C 10 pts C i 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 F is .met E is met <br /> Minimum Depth to groundwater from the Sail Sample (feet) T L} >100 51-100 25-50\1 <br /> Fractures in sulosurfiace (applies to foothills or mountain areas) <br /> None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxx:c:cx 26-40\2 <br /> Man-Made conduits which increase vertical migration None I Unknown Present <br /> of leachate (i.e., septic systems, water wells, ponds) I <br /> At least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None one one <br /> COLUMN TOTALS>>TOTAL POINTS I + + - <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 4$ pts 40 pts or less <br /> _ <br /> ' IJi r I) V B` T x E `B ` T I X 1 E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 11 50 50 50 3 li 3 1. 1. NA\3 <br /> Sample Result: <br /> GASOLINE 1000 100 10 <br /> #i� <br /> -I Yti _ 1 t MAXIMUM ALLOWABLE TAH LEVELS (PPM) 100 <br /> TPH I> DIESEL 10,000 1000 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the Lea cKing- eritial� <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. P! P (diesel). <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 (gasoline) or 100 <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Altowabie Levels *Yes Na /! <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 / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />