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I <br /> SAN JOAQUIN Cl PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAr�JIVI5I0N GATE 1 C rl <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> 100 <br /> I, <br /> SWEEPS CODE <br /> !NAME OF FACILITY <br /> r IFI <br /> TANK ED 9131 <br /> ;ADDRESS <br /> i (TANK SIZE FUEL TYPE 1,1 <br /> W I� <br /> II. GENERAL SITE HIS '**' <br /> current? Yes Na Permit'# " <br /> Facility Status Code C Doc.soiL/GW Cont Yes No <br /> Is per <br /> II ':,Number of Tanks at facility j Age of Tanks(if avaiLable) Type of Tank steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> ;Was Tank tested? Yes 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 INo BTXE TPH'G TPH-D Pb/EDB <br /> ,Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH IN ECT'ION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) i <br /> "Soil Samples Received Yes No ` Depth to Ground Water �jo Ref/Year Average Annual Precipitation A= 14 10-25 <br /> on-Site Wells) Yes No Number & Type Irr Dom Pub <br /> S Score S Score S score <br /> -� ft C 10 pts C 9 pts C 51pts <br /> 'Distance to Wells) from Tank ft; ft% O if a if a if <br /> R condition R condition R condition <br /> V, Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> :Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 5 25-50\1 <br /> Fractures in subsurface Capplies'to foothills or mountain areas) .None Unknown Present <br /> 'Average Annual Precipitation (inches) xxxxxx <10 9 10'25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration 1 `'� <br /> ioi leachate (i.e., septic systems, water wells, ponds} <br /> f v None Unknown Present <br /> At least) More than <br /> .Unique site features: Recharge area, coarse "soil, nearby wells. xxxxxx None ane one. <br /> .v <br /> COLUMN TOTALS—TOTAL POINTS + + <br /> ;Sample Result: CB T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - is 40 pts or less <br /> 1L B T X E B JT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50� 50 .3 .3 1. 1. NA\3 <br /> j 3 <br /> GASOLINE 1000 0 10" <br /> ;Sample Result: <br /> i Z`� MAXIMUM ALLOWABLE TPH LEVELS (PPM) . <br /> -TQw� JC TPH DIESEL 10,000 1000 100 <br /> �iOOTNOTES: ***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 D.points. If depth ­5 ft., do not use tahLe. <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 /> IT. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allow ble Levels *Yes Na <br /> 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for EvalezatioR <br /> V;1. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITiGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> 5 <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/99 <br />