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SAN JOAQUIN OY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H# DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE S z 8163 <br /> NAME OF FACILITY A*)r � ,f„Y 4r SWEEPS CODE <br /> ADDRESS JL4 S. Wy tljTANK ID # - <br /> TANK SIZE FUEL TYPE TAAV_S S k W <br /> 11. GENERAL SITE HISTORY 1` G �DS� slti� <br /> *** <br /> Is permit current? Yes I'A, No I Permit # - Facility Status Code Doc.SoiL/GW Cont Yes X No <br /> Number of Tanks at facility 3 Age of Tanks(if available) Type of Tank Steel FbrgL S9 Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No If yes, give gto(s) <br /> Was a repair made to the tank system? Yes x No If yes, what was repaired? P► h Tfena+^ 9464;&\ rcma <br /> Was repair done under inspection? Yes x <br /> No Were soil samples analyzed? Yes No 1 BTXE TPH-G X 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 k No Depth to Ground Water I Ref/Year 1 419 1 Average Annual Precipitation A=114 10-25 <br /> On-Site WeLI(S) Yes No Number 8 Type Irr Dom I Pub - <br /> S Score S Score S Score <br /> Distance to Well(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> o 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 /> Minimum 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 <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 /> AAjG r2 OI xxxxxx None lJt one one <br /> D1 » <br /> � COLUMN TOTALS >TOTAL POINTS 'Ar16 _ <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> B T I 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 /> (01� r?A b MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH 17 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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Reco rd Site Closure)Yes INo E*tf Yes, Refer to Site Mitigatio <br /> n.�Rec� n for EvaLuati on <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CORCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED ��/ ��/ d3 DATE CLOSURE LETTER MAILED / / <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />