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SAN JOAQUIN C%w y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL, 3DIVISION <br /> I• ,,11 UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE 1p 3c OZ <br /> NAME OF FACILITY A R1,0Q b l i SWEEPS COOE <br /> 1', <br /> (ADDRESS Sb I W( 0 I G`A^*R j L4,-k/ TANK ID #10 S' <br /> TANK SIZE 12o { ZZ FUEL TYPE Q f Pe k O( <br /> [I. GENERAL SITE HISTORY '^ <br /> �srf� Mi <br /> Is permit current? Yes \(! No Permit # r ` I le7 ?(M Facility Status Code DOc.SoiL/GW Cont Yes No X <br /> 'Number of Tanks at facilityAge of Tanks(if available) Type of Tank Steel Fbrgl X Sngll Dual <br /> 3 <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes Nyes, give date(s) <br /> o If <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 TPH-0jj <br /> 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 /> i <br /> Soil Samples Received Yes X No Depth to Ground Water J Ref/Year �p�J Average Annual Precipitation A= 14 10-25 <br /> On-Site W@LL(s) Yes No Number & Type Irr Dan Pub <br /> S Score S Score S Score <br /> Distance to Well(s) from Tank y 1 4D it; ft; ft C 10 pis C 9 pts C 5 pis <br /> 0 if 0 if O if <br /> R condition R condition R condition <br /> IV. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> lMinimm 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 C, <br /> 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) l 0 None Unknown Present <br /> jUnique site features: Recharge area, coarse soil, nearby wells. At Least More than <br /> xxxxxx None ?� one we <br /> COLUMN TOTALS»>TOTAL POINTS o + J + <br /> ,Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> /, a T X E B T X E <br /> V MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> i <br /> .Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> ��TPN 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 BTX&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION DA CY 1 Goo —CU/-� <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels •Tes No ` <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation farEvaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES I NO I REFERRED TO SITE MITIGATION FOR EVALUATION YESI 110 <br /> DATE REFERRED ` / / O DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />