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SAN JOAQUIN COL.... PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL} VISION <br />I UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE —/0 <br />NAME OF FACILITY S C C ; -� L.1 (SWEEPS COOEI 3 / o <br />ADDRESS( / /la (TANK ID � 3 - 2 E d2 <br />TANK SIZE FUEL TYPE r p <br />II. GENERAL SITE HISTORY *** <br />Is permit current? Yes x No (Permit 0 - (Facility Status Code V � Doc.Soil/GW Cont Yes No <br />Number of Tanks at facility �� Age of Tanks(if available) 1.; Type of Tank lSteel Fbrgl Sngll Dual <br />III. TANK HISTORY 1253 <br />Was Tank tested? Yes <br />No (Failed precision test ? Yes Ho 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? Yes 1111101 (Were soil samples analyzed? Yes NoI BTXEI 1TPH-G TPH-OI Pb/EDB( <br />(Type of failure/discharge (catastrophic (long-term leakage) loverfill unknown other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Spit Samples Received Yes INo Depth to Ground Water 1Ref/Year , <br />Average Annual PrecipitationlA=114 110- <br />On-Site WeLL(s) Yes No Number & Type Irr IDomi Pub1 <br />S Score S Score S Score <br />Distance to WeLL(S) from Tankl 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 <br />E is met - is met E is met <br />Minimum Depth to groundwater frau the Soil Sample (feet) <br />u D 1 >100 I 151-100 ( 1 25-50\1 <br />(Fractures in subsurface (applies to foothills or mountain areas) <br />i None i I Unknown (Present <br />Average Annual Precipitation (inches) <br />xxxxxx <10 I 9 110-25 lxxxxxxxl 26-40\2 <br />�Man-Made conduits which increase vertical migration I None I I Unknown (Present <br />leachate (i.e., septic systems, water wells, ponds) <br />R I At Least More than <br />Unique site features: Recharge area, coarse soil, nearby wells. xxxxxxl None one one <br />lid, <br />COLUMN TOTALS>>>TOTAL POINTS <br />Sample Result: (8 T X OR E) <br />RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br />n �� n� D B T X E B XI EIv MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50I 50 5 .3 I.T <br />3 11.1 1. NA\3 <br />GASOLINE 1000 100 10 <br />Sample Result: <br />A (I &� D MaxIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL 10,000 1000 100 <br />TPH <br />FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not <br />e 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 />1 \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 1 <br />1. Are BTX & E or TPH CoERRW <br />) INo �tq S3?, Recommend Site Clasur Site Mitigation for 'Evaluation IvC�r <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR ll' <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYESI INOI (REFERRED TO SITE MITIGATION FOR EVALUATIONIYES INOI I <br />DATE REFERRED / / DATE CLOSURE LETTER MAILED / / <br />NAME OF <br />EVALUATOR! <br />EH 23 80 (UGTWKSHT)\5/90 <br />