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SAN JOAQUIN C* PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE*DIVISION _ _ <br /> 1 UuST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY �,� G GV eS SWEEPS CODE ` O � <br /> - TANK [0 # <br /> ADDRESS ® <br /> TANK SIZE Z, FUEL TYPE <br /> (I. GENERAL SITE HISTORY - ��� <br /> Is permit current? Yes No Permit # - Facility Status Cade Dcc.Soil/GW Cont Yes No <br /> Number of Tanks at faciLity Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes Na I XlFailed precision test 7 Yes No <br /> !Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> aas repair done under inspection) Yes No Were soil samples ana lyzed7 Yes No STXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic Long-term leakage overfill unknown other: <br /> !V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water " L) Ref/Year S_Gj Average Annual Precipitation A-114 10-25 <br /> On-Site WeLL(s) Yes No Number 8 Type Irr Dao Pub <br /> S Score S Score S Scare <br /> Distance to WeLL(s) from Tank ft; ft; ft C 10 pts C 9 pis C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leeching Potential Analysis E is met E is met E is met <br /> Minimam Depth to groundwater from the Soil Sample (feet),3o - 7 = >100 51-100 O Z5-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) V 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 /> I �J <br /> COLUMN TOTALS>>>TOTAL POINTS [J O f + � - 37 <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pis or more 41 - 48 pts 40 pts or less <br /> T X E 8 T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> (Sample Result: GASOLINE 1000 100 10 <br /> N,� MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> D 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 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 BTX8E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF tECOIRdENDATION/CONCLUSION 'ae_�' oyt <br /> !' N ^/ S <br /> 1. Ara BTX & E or TPH Concentrations > Allowable Levels 'Yes No ~ CSI-�N/K#�(/�✓ � J�a-}� <br /> 2. Recoend Site Closure Yes No 'If Yes, Refer to site Mitigation for Evaluation <br /> mm <br /> ILL. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISGR/SENIOR ..•• Gf/� - sl4?CtY <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YEs NO REFERRED TO SITE MITIGATION FOR EVALUATION YES ✓NO <br /> DATE REFERRED > / "'�A13 /L'1 ! DATE CLOSURE LETTER MAILED / / <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />