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SAN JOAQUIN L.JNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HES- H DIVISION <br />UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br />NAME OF FACILITY (SWEEPS CODE <br />(ADDRESS TANK ID 9 <br />I <br />!TANK SIZE FUEL TYPE <br />II. GENERAL SITE HISTORY <br />Is permit current? Yes No Permit # - Facility Status Code Doc.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? <br />Yes <br />REFERRED TO SITE MITIGATION FOR EVALUATION <br />No <br />Failed precision test ? <br />Yes <br />A= <br />No <br />If <br />yes, give dates) <br />Was a repair made to the tank system? <br />Yes <br />Nol If yes, what was repaired? <br />Uas repair done under inspection? <br />Yes <br />ub P <br />No (Were soil samples analyzed? <br />Yes NoI <br />S <br />C <br />0 <br />R <br />E <br />BTXE TPH-G <br />TPH-0 <br />Score <br />5 pts <br />if <br />condition <br />is met <br />Pb/ED3 <br />I <br />;Type of failure/discharge <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />catastrophic <br />tong -term Leakage overfill <br />unknown <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALTSI�)) <br />Soil Samples Received Yesl No <br />i <br />REFERRED TO SITE MITIGATION FOR EVALUATION <br />Depth to Ground Water <br />Ref/Year <br />Average Annual Precipitation <br />A= <br />14 10-25 <br />On -Site WeLL(s) <br />Yes <br />FFE <br />J__ <br />Number & Type <br />Irr Dom <br />ub P <br />S <br />C <br />0 <br />R <br />E <br />Score <br />10 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />9 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />5 pts <br />if <br />condition <br />is met <br />'Distance to WeLL(s) from Tank ft; ft; ft <br />jV. Site Feature - Leaching Potential Analysis <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />51-100 <br />25-50\1 <br />(Fractures in subsurface (applies to foothills or mountain areas) <br />I <br />None <br />Unknown <br />Present <br />,Average Annual Precipitation (inches) <br />xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />jof leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />(Present <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />xxxxxx <br />None <br />At least <br />one <br />More than <br />one <br />i <br />COLUMN TOTALS»>TOTAL POINTS ` ` <br />Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 - 48 pts 40 pts or less <br />i X E B T X E <br />j MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 175 50I 50 .3 .3 1. <br />;Sample Result: GASOLINE 1000 100 10 <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />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 BTX&E 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 />I <br />2. Recommend Site Closure Yes No I*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 <br />REFERRED TO SITE MITIGATION FOR EVALUATION <br />YES NO <br />DATE REFERRED <br />DATE CLOSURE LETTER MAILED <br />NAME OF <br />EVALUATOR <br />J__ <br />EH 23 80 (UGTWKSHT)\5/90 <br />