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SAN JOAQUIN COI,. Y' PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL'. ,DIVISION � <br />UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE_ <br />I. <br />C <br />�� - - l SWEEPS ODE / D <br />NAME OF FACILITY D t- c <br />ADDRESS 27 <br />TANK ID # 3 ' G T 7- Q <br />TANK SIZE / FUEL TYPE r, <br />II. GENERAL SITE HISTORY *** <br />Is permit current? Yes No Permit # - Facility Status Code Q ( Doc.Soil/GW Cont Yes No <br />Number of Tanks at facility <br />Age of Tanks(if available) 0 Type of Tank Steel Fbrgt Sngl Dual <br />�# 7 <br />III. TANK HISTORY <br />Was �Tank�stedff��em? <br />led precision test ? Yes No If yes, give dates) <br />Was Yes No If yes, what was repaired? <br />Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPH-D Pb/EDB <br />(Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received Yes No Depth to Ground Water t) Ref/Year � ; Average Annual PrecipitationA= 14 10-25 <br />On -Site Well(S) Yes No Number & Type Irr Dom Pub <br />S Score S Score S Score <br />Distance to Wells) 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 lis met E is met <br />Minimum Depth to groundwater from the Soil Sample (feet) d.— <br />>100 51-100 125-50\1 <br />h None Unknown (Present <br />Fractures in subsurface (applies to foothills or mountain areas) lJ <br />Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxxl 26-40\2 <br />Man -Made conduits which increase vertical migration None Unknown Present <br />of leachate (i.e., septic systems, water wells, ponds) <br />At least More than <br />Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None one one <br />- 2- <br />COLUMN TOTALS»>TOTAL POINTS G,Q � <br />Sa le Result: (B T X OR E)j RANGE OF TOTAL POINTS 49 pts or more 41 - is 40 pts or less <br />�p A B T X E X I E 11 <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 50 I/B <br />J.T <br />3 11.! 1. NA\3 <br />ry GASOLINE 1000 100 10 <br />Sample Result: `.� <br />n � J „ v MAXIMUM ALLOWABLE TPH LEVELS (PPM) 100 <br />j' 41 TPH DIESEL 10,000 1000 <br />FOOTNOTES: <br />***If documented soil and/or ground water contamination is present, do no -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 p (diesel). <br />VI. STAFF RECOMMENDATION/CONCLUSION a `✓`� L <br />1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br />2. Recommend Site Closure Yes No *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 CLOSURE YE5 IMO REFERRED TO SITE MITIGATION FOR EVALUATIONIYES INC! <br />ffNAME <br />REFERRED / / <br />DATE CLOSURE LETTER MAILED' <br />OF <br />EVALUATOR! <br />EH 23 80 (UGTWKSHT)\5/90 <br />