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SAN JOAQUIN COU - UBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTk4SION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY (SWEEPS CODEI <br /> ADDRESS TANK ID # - <br /> TANK SIZE (FUEL TYPE <br /> II. GENERAL SITE HISTORY v t, <br /> *** <br /> Is aermit current. Yes r No Permit #I <br /> - lFacility Status Code Doc.SoiL/GW Cont Yes FTN.7 <br /> ,Nunber of Tanks at facility Age of Tanks(if available)( (Type of TanklSteetl (Fbrgll Sngl Dual <br /> III. TANK HISTORY <br /> Was tank tested?IYesNol Failed precision test ?IYes INoi �If yes, give date(s)17//6 <br /> Was a repair made to the tank syst.?Iy.slx No F If yes, what was repaired? / <br /> was repair done under inspection?IYes INo Were soil samples analyzed? Yes ;NoI BTXE (TPH-GI (TPH-D) Pb/EDB! <br /> catastrophic long-term leakage, <br /> Type of failure/discharge ( overfill lunknownl other: <br /> i <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> (Soil Samples Received�Yesl NO! !Depth to Ground Water Ref/Year jAverage Annual Precipitation A=114 `10-25 <br /> jOn-Site Wetl(s)IYes NoI INu ber & Typel Irr Dom 1publ <br /> S Score S Score S (Scare <br /> Distance to WeIL(S) from Tankj ft; ft; ft C 10 pts C 9 pts C 5 pts I <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> 1V. Site Feature - Leaching Potential Analysis c" is met E is met E is met <br /> lminimun Depth to groundwater from the SoiL Sampte (feet) { >100 151-100 25-50\1 <br /> 'Fractures in subsurface (applies to foothills or mountain areas) None + Unknown lPresent <br /> Average Annuat Precipitation (inches) xxxxxxl <10 I 9 I 110-25 Ixxxxxxx` 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> hof .eacnate (i.e., septic systems, water wens, ponds) None Unknown l ,Present <br /> `unicue site features: Recharge area, coarse soil, nearby weds. I At least (More than <br /> I xxxxxx None I one one <br /> COLUMN TOTALS>>>TOTAL POINTS, + 1 + <br /> � <br /> ;Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more ( 41 48 pts 40 pts or Less <br /> K, 5 z /� D MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50) 50� SO 3 3 ( 1.1 1. I <br /> NA\3 <br /> Sample Re ult: 'GASOLINE 1000 I 100 I 10 <br /> J1� + S '• MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH C-r 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 Levets for STX8E 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) INo <br /> 2. Recommend Site CLosureiYesj INol 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 CLOSUREIYESI IND! REFERRED TO SITE MITIGATION FOR EVALUATION YES N01 <br /> DATE REFERRED( / / DATE CLOSURE LETTER MAILED I I <br /> NAME OF <br /> EVALUATOR! <br /> EH 23 80 (UGTWKSHT)\5/90 <br />