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SAN JOAQUIN COI,..., PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL (VISION <br />DATE <br />UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br />I <br />'SWEEPS CODE' a 3/ <br />D <br />NAME OF FACILITY Sit U <br />D <br />/ (TANK ID T �� - <br />ADDRESS <br />7) c7 <br />(FUEL TYPE <br />vI—e-42-. <br />I1. GENERAL SITE HISTORY <br />**� <br />Yes <br />NO (Permit 4 <br />- 'Facility Status Code <br />DOC.SoiL/GW <br />Cant Yes <br />No <br />Is permit current? <br />Cf <br />3 I <br />Type of TanklSteel <br />1Fbrgl <br />sngl Dual <br />Number of Tanks at facility) <br />Age of 7anks(if available) <br />III. TANK HISTORY <br />Was Tank tested? <br />Yes) No 'Failed precision test ?'Yes) No <br />If yes, give71 <br />Was a repair made to the tank system? <br />Yes <br />No If yes, what was repaired. <br />Were soil samples analyzed?'Yes NoI BTXE <br />TPH-GI <br />'TPH-O) Pb/EDS' <br />'Was repair done under inspection? Yes <br />INo <br />(Type of failure/discfiargel catastrophic <br />Ilona -term leakage) )overfill) unknown <br />(other: <br />HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />IV. REMOVAL <br />Average Annual PrecipitationlA=114 <br />10-25 <br />Soil Samples Received <br />Yes1 No Depth to Ground Water 'Ref/Year <br />; <br />On -Site Well(s) Yes No <br />Number & Type <br />Irr IDoml IPub <br />S <br />Score <br />S Score <br />S Score <br />Distance to Wells) from Tank ft; ft; ft <br />C <br />O <br />10 pts <br />if <br />C 9 <br />0 <br />pts <br />if <br />C 5 <br />0 if <br />pts <br />R <br />condition <br />R <br />condition <br />R <br />condition <br />V. Site Feature - Leaching Potential Analysis <br />is met <br />E <br />is met <br />E <br />is met <br />Minimus Depth to groundwater frau the Soil Sample (fest) I_ <br />I <br />>100 I <br />151-100 <br />i <br />125-50\1 <br />(Fractures in subsurface (applies to foothills or mountain areas) <br />C, <br />I None I <br />Unknown <br />(Present <br />Xxxxxx <br /><10 I <br />9 110-25 <br />Ixxxxxxxl <br />26-40\2 <br />(Average Annual Precipitation (inches) <br />Man -Made conduits which increase vertical migration <br />None 1 <br />I <br />Unknown <br />(Present <br />of leachate (i.e., septic systems, water wells, ponds) <br />I <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />xxxxxx <br />None <br />11 <br />At least) <br />one <br />More than <br />one <br />\' <br />COLUMN TOTALS>>>TOTAL POINTS <br />Sample Result: (B T X OR E) RANGE OF TOTAL POINTS <br />49 pts or more I 4 <br />40 pts or Less <br />cJ .�7a ND aT� <br />B T X E <br />KB <br />JT <br />X E <br />11.1 <br />NA\3 <br />q3TA XIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />1I 501 501 50 <br />.3 .3 <br />1. <br />GASOLINE <br />1000 <br />100 <br />10 <br />Sample Result: <br />N <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />DIESEL <br />10,000 <br />1000 <br />100 <br />r TPH <br />FOOTNOTES: ***If documented soil and/or ground water contamination is present, do no ete t e leaching potential <br />Contamination List for soil or ground water.) <br />analysis. (i.e., site is currently on UGT <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. p� (gasoline) or 100 ppm (diesel). <br />at a TPH concentration of 10 <br />\3 Levels for BTX&E are not applicable <br />VI. STAFF RECOMMENDATION/CONCLU5IUH <br />¢ � a/ <br />"`a'- <br />1. Are BTX & E or TPH Concentrations > Allowable Levels *Yell No <br />?, Recommend Site Closure Yesl No' �*If Yes, Refer to Site Mitigation for 'cvaluation �pQ� # - q <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR lS <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYESI INOI IREFERRED TO SITE MITIGATION FOR EVALUATIONIYES1 INOI I <br />DATE REFERRED' / ! DATE CLOSURE LETTER MAILEDI / ! <br />NAME OF <br />EVALUATORI <br />EH 23 80 (UGTWKSHT)\5/90 <br />