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SAN JOAQUIN C& PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA#IVISION <br /> 1, UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE g 23 <br /> NAME OF FACILITY 4 1 SWEEPS CODE <br /> (ADDRESS3 /Scp, _ TANK ID # —0 <br /> !TANK SIZE FUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> e*r <br /> Is permit current? Yes No Permit # - Facility Status Code Doc.Soi L/GW Cont Yes No <br /> Naber of Tanks at facility / Age of Tanks(if available) (Type of Tank Steel FbrgL Sngll Dual <br /> III. TANK HISTORY r <br /> ;Was Tank tested? Yes No Failed precision test ? 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 ed? Yes No Were soil samptes analyzNo BTXE TPH-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 Water Ref/Year Average Annual Precipitation A=114 10-25 <br /> On-Site WeLL(s) Yes No Number 8 Type Irr Dam Pub <br /> S Score S Score 5 Score <br /> 'Distance to WeLL(S) from Tank ft; ft; ft C 10 pts C 9 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 E is met E is met <br /> !Minimmn Depth to groundwater from the Soil Sample (feet) >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 )TT <br /> I!of leachate (i.e., septic systems, water wells, ponds) / v None Unknown Present <br /> ;Unique site features: Recharge area, coarse soil, nearby wells. 61 At Least More than <br /> xxxxxx None O 1�/ one one <br /> COLUMN TOTALS>»TOTAL POINTS0 + V I + <br /> ,Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> 41 z ,0/(7), .ozic\b, --- <br /> i.fI —> IlT X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1j NA\3 <br /> ,Sample Result: '" GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> ?t/ TPH 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 UST 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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> Vt. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concent rat tjdns > Allowable levels *Yes No ' <br /> ! 2. Recommend Site Closure Yes INT If Yes, Refer to Site Mitigation for Evaluation <br /> V!!. 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 />