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SAN JOAQUIN CL_ .Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL IVISION <br />I UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE 3 <br />NAME OF FACILITY v (SWEEPS CDOEI <br />ADDRESS 3 r A �� ITAHK ID T L ? T— <br />TANK SIZE I �% O C) C) FUEL TYPE CL/ �Q �Stc) C r" le _S ��+P l� g <br />II. GENERAL SITE HISTORY *.. <br />Is permit current? Yes No Permit - Facility Status Code �^ 1611 -- <br />s <br />Cant No <br />Number of Tanks at facility Age of Tanks(if available) (Type of Tank Steel Fbrgl Sngl Dual <br />III. TANK HISTORY <br />Was Tank tested?[Yes INo (Failed precision test fly esl No If yes, give date(s) <br />Was a repair made to the tank system? Yes NoI If yes, what was repaired? <br />Was repair done under inspection? Ye [NoI Were soil samples analyzed? Yes NoI BTXEI ITPH-GI ITPH-O Pb/EDB <br />Type of failure/discharge) catastrophic long -tens leakageI overfill unknown) lother: <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 , <br />(Average Annual PrecipitationlA= 14 10-25 <br />Irr Dom Pub <br />On -Site Well(s)IYes [No I Number & Typel I I I S Score S Scare 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 is met E is met <br />IMiniman Depth to groundwater from the Sail Sample (feet) <br />>100 151-100 I 25-50\1 <br />r l None I I Unknown Present <br />(Fractures in subsurface (applies to foothills or mountain areas) ) <br />Average Annual Precipitation (inches) <br />xxxxxx <10 I 9 110-25 Ixxxxxxxl 26-40\2 <br />Man -Made conduits which increase vertical migration None I Unknown I (Present <br />or leachate (i.e., septic systems, water wells, ponds) <br />/� I At least More than <br />(Unique site features: Recharge area, coarse sail, nearby wells- xxxxxxl None `-11 one one <br />COLUMN TOTALS>>>TOTAL POINTS ` IJ7 I + 15 <br />40 is or less <br />Sample Result: (B T X OR E) RANGE OF TOTAL POIN7S 49 pts or more I 41 - is I P <br />B TI5IE .B I.1 IXIE <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 50 3 3 1.� 1. NA\3 <br />Sample Result: <br />GASOLINE 1000 100 10 <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL 10,000 1000 I 100 <br />VJ TPH <br />FOOTNOTES: <br />***If documented soil and/or ground water contamination is present, do not coWLete the leaching potential <br />analysis. (i.e., site is currently on UG7 Contamination list for sail 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, scare 0 points. <br />\3 Levels for STX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOMMENDATION/CONCLUSION +0 L.k <br />1. Are BTX b "c or TPH Concentrations > Allowable Levels *Yes NoI (f 7-W 4 KS <br />2.Recommend Site Closure Yes No <br />VII. REVIEW EVALUATION - TO BE I*If Yes, Refer to Site Mitigation for Evaluation Il�Z-oR� <br />COMPLETED BY A SUPERVISOR/SENIOR <br />W� <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYES IND, (REFERRED TO SITE MITIGATION FOR EVALUATIONIYES) INOI I <br />DATE REFERRED[ (DATE CLOSURE LETTER MAILED[ I, <br />NAME OF <br />EVALUATOR <br />EH 23 30 (UGTWKSHT)\5/90 <br />