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SAN JOAQUIN Ct.,__.Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL [VISION DATE <br />UGST WORKSHEET FOR SITE CLOSURE EVALUATION — <br />I. <br />} \ SWEEPS CODE' �j <br />NAME OF FACILITY J _ <br />ADDRESS ��� y v <br />TANK.' 7 <br />TANK SI <br />' i f �' <br />SIZE FUEL TYPE ��I <br />II. GENERAL SITE HISTORY <br />Is permit current?[Yes No 'Permit - Facility Status Code 'Doc_Soil/GW Cant Yes No <br />Number of Tanks at facility 'Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Oual <br />III. TANK HISTORY <br />Was Tank tested? Yes 'No (Failed precision test Yes' No 'If yes, give date(s) <br />Was a repair made to the tank system? Yes No If yes, what was repaired?' <br />iWas repair done under inspection?IYes 'No' (Were sail samples analyzed? Yes No BTXE' '7PH-G' ITPH-D Pb/EDB <br />(Type of failure/discharge) catastrophic long-term leakage) 'overfill unknawnl (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 Ref/Year' 'Average Annual Precipitation'A='14 10-25 <br />On-Site Well(S) Yes' Nol Number & Type' Irr' 'Dant 'Pub <br />S Score S Score S Score <br />Distance to Wells) frau 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 <br />is met E is met E is met <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />>100 I 151-100 ' 25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />' None ' ' Unknown ' [Present <br />Average Annual Precipitation (inches) <br />xxxxxx <10 ' 9 110-25 Ixxxxxxx' 26-40\2 <br />Man-Made conduits which increase vertical migration I None I ' Unknown I (Present <br />of leachate (i.e., septic systems, water wells, ponds) <br />At least) (Mare than <br />Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx More one one <br />COLUMN TOTALS»>TOTAL POINTS <br />Sample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts, 40 pts or less <br />F_I --/* �)1) B T X E a x E <br />MAXIMUM ALLOWABLE a-T-X-E LEVELS (PPM) 1 50I 50I 50', j 3 J.T <br />3 11.E 1. NA\3 <br />l GASOLINE 1000 � 100 10 <br />Sample Result: pf ~0 A) MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />I)� TPH DIESEL 10,000 1000 100 <br />FOOTNOTES: ***If documented soil and/or ground water contamination is present, do notc` —an`p a-the leaching potential <br />analysis. (i.e., site is currently on UGT 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 />\Z if precipitation is > 40 inches, score 0 points. <br />\3 Levels for STX&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />V1 . STAFF RECOMMENDATION/CONCLUSION� �'�l <br />�cL <br />1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No l ! ,& <br />I Yes <br />2. Recommend Site Closure No *If Yes, Refer to Site Mitigation for Evaluation <br />I � <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR 1 7 <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYES INO (REFERRED TO SITE MITIGATION FOR EVALUATIONIYES INOI <br />DATE REFERRED / / <br />(DATE CLOSURE LETTER MAILED' <br />NAME OF <br />EVALUATOR <br />E4 23 3C (UGTWKSHT)\5/90 <br />