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SAN JOAQUIN COU*BLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH*SION DATE <br /> I UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> `r / IN SWEEPS CODE <br /> NAME OF FACILITY J'— <br /> ADDRESS 1 I(4 N VlCf A&k, C TANK ID # <br /> TANK SIZE FUEL TYPE FJ� s <br /> it. GENERAL SITE HISTORY �* <br /> is permit current? Yes No Permit # - Facility Status Code Doc.Soil/GW Cont Yesl No <br /> Number of Tanks at facility Age of Tanks(if available) IType of Tank'Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yesl 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 No Were soil samples analyzed? Yes No BTXE TPN-G TPN-D Pb/EDB <br /> Type of failure/discharge Icatastrophic 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 Co Ground Water Ref/Yearis <br /> rage Arn,al Precipitation A=I 14 10-25 <br /> On-Site WeIL(s) Yes l No Number & Type l Oan Pub S Scare S Scare <br /> Distance to WeLI(s) from Tank ft; ft; ft C 9 pts C 5 pts <br /> 0 if 0 if <br /> R condition R condition <br /> V. Site Feature - Leaching Potential Analysis "c is met E is met <br /> Minimum Depth to groundwater frau the Soil Sad e e') n15 00 I S ZS-50\1Fractures in subsurface (applies to foothills or mountain areas) nown Present <br /> Average Annual precipitation (inches) xxxx25 xxxxxxx 26-40\2Man-Made conduitswhich increase vertical migration nown I Present <br /> of Leachate 0.e., septic systems, water wells, ponds) <br /> At Least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. XXXXXX Nane one one <br /> COLUMN TOTALS»,TOTAL POINTS �/ I + <br /> S moil Result: (B T X OR c) <br /> RANGE OF TOTAL POINTS 49 pts or more f 1 48 40 pts or mess <br /> 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 /> Sample Resin'• GASOLINE 1000 I 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) I 1000 I 100 <br /> _TPN � DIESEL 10,000 <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 sail 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 BTX&E are not applicable at a TPH concentration of 1O ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & 'c or TPH Concentrations > Allowable Levels •Yes No <br /> 2. Recommend Site Closure Yes Lilo *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 NOI REFERRED TO SITE MITIGATION FOR EVALUATION YES NO! <br /> rV <br /> E REFERRED / / DATE CLOSURE LETTER NAILEDE OF <br /> LUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />