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4/ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION q <br /> I UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> NAME OF FACILITY ( SWEEPS CODE` <br /> ADDRESS DEQ t TANK ID # <br /> TANK SIZE - FUEL TYPE P <br /> II. GENERAL SITE HISTORY <br /> ,r,r* <br /> 11s permit current? Yes No Permit # - Facility Status Code Doc.SoiI/GW Cont Yes No <br /> Number of Tanks at facility (Age of Tanks0 f available) Type of TankjSteel 1Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> 'Was Tank tested? Yesl No) Failed precision test ? Yes No If yes, give dates) <br /> was a repair made to the tank system?lYesj No If yes, what was repaired? <br /> I <br /> was repair done under inspection? Yes No Were soil samples analyzed? Yesl No BTXEI TPH-GI TPH-DI IPb/EDB Ll <br /> Type of failure/discharge) catastrophic long-term leakage overfill unknown 'other: <br /> IV. REMOVAL HISTORY (ATTACH INSP TION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Waterit Ref/Year b (Average Annual PrecipitationlA=114 10-.51 <br /> IOn-Site Wells) Yes No ONumber & Type Irr Dom Pub <br /> S Score S Score S Score <br /> ;Distance to Wells) from Taft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is :net i E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) ��F"F I >100 I 151-100 I aI 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) /"� None 1 I Unknown I iPresent <br /> Average Annual Precipitation (inches) xxxxxx <10 j 9 10-25 xxxxxxxl 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> for leachate (i.e., septic systems, water wells, ponds) None I C1 Unknown (Present <br /> 'Unique site features: Recharge area, coarse soil, nearby wells. �/�I� At least More than <br /> xxxxxx None 1 one one <br /> ICOLUMN TOTALS>>>TOTAL POINTS + 124 I lA 1 <br /> Sre Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 48 pts / "pts or_less <br /> 6_ N�� AD B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 501 50 ( .3 .3 1. 1. r NA\3 <br /> Sample Result: <br /> GASOLINE 1000 100 10 <br /> N gMAXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> 1 TPH DIESEL 10,000 ( 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the le.ch ng 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). II <br /> VI. STAFF RECOMMENDATION/CONCLUSION C <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No cJ��`G RPh <br /> 2. Recommend Site Closure YesNo if Yes, Refer to Site Mitigation for Evaluation .1� <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/ ENIOR IV <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES( VINOI (REFERRED TO SITE MITIGATION FOR EVALUATIONIYES N01 <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF ) <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />