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SAN JOAQ N COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTALTH DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE _ <br /> NAME OF FACILSTY SWEEPS CODE g' Q <br /> ADORESS QJ"� TANK ID # 3 1 u <br /> TANK SIZE—j &OD FUEL ,TYPE geq, pd1)r'Uj;tq, Gt <br /> It. GENERAL SITE HISTORY <br /> Iis permit current? Yesl No (Permit *I I Facility S,atus Cade) Dac.Soil/GW Cant Yes INoI <br /> Number of Tanks at facility Age of Tanks(if available)( i�Type of Tank Steel IFbrgll Sngl Oual <br /> III. TANK HISTORY <br /> Was Tank tested?IYes No Failed precision test ? Yes No If yes, give dare(s) <br /> Was a repair made to the tank system? yesl Nol If yes, what was repaired?I <br /> Was repair done under inspection? Yes NoI Were soil samples analyzed?I YesI NoI BTXEI ITPN-GI TPH-OI Pb/EDB( <br /> Type of failure/discharge catastrophic long-term Leakage) IoverfiL LI Iu in own other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No IDepth to Ground Water Ref/Year Average Annual Precipitation A= 14 10-25 <br /> On-Site Well(s)IYes No INuiber 3 Type Irr I (Doml Publ S Score S ScoreS Score <br /> Distance to ueLL(s) from Tank ft; 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 met E is met E is met <br /> minimum Depth to groundwater from the Soil Sample (feet) Cj— � <,' I >100 I I51-100 I - 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) I More I Unknown I (Present <br /> Average Annual Precipitation (inches) xxxxxx <10 I 9 10-25 IxxxxxXx 26-40\2 <br /> Nan-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systema, water wells, ponds) Q None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. I At Least More than <br /> ne <br /> XXX)= Noone one <br /> -5 Pei #q- 13 1aW <br /> COLUMN TOTALS»>TOT HIS <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 - 4a pis I 40 pts or less <br /> 8 T X E 8 X E <br /> /�� 1� Ih ll/K- •i OMiIxIMUM ALLOWABLE S-i-X-E LEVELS (PPM) 1 50 50 50 .3 .TT 1. 1. I NA\3 <br /> Sampley�ResuLt:�� GASOLINE 1000 100 I 1G <br /> S I I�, ✓ MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> iS1 PX DIESEL 10,000 1000 I IOD <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 m5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppa (gasoline) or 100 ppm (diesel). <br /> VI. STAFF REC0MMENDATION/CONCLUSION _-/ - S- oGK I f /e— uJA Lc.Q[.oQ <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels `Yes _ No I -ro KJ <br /> 7RhJfC <br /> 2. Recommend Site Closure Yes No It Yes, Refer to Site Mitigation for Evaluation S D r �) 6611 <br /> 61�'�� <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR ! (O n-2 <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE I YES( NO (REFERRED TO SITE MITIGATION FOR EVALUATIONITESI IND <br /> DATE REFERRED DATE CLOSURE LETTER MAILED / / <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />