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1 <br /> SAN JOAQUIN . Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE DIVISION <br /> I uGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> �t � WEEPS CODE I c2GATE 3 I / �' <br /> NAME OF FACILITY A c.n TI <br /> C-l_/Cl 7ANK ID <br /> ADDRESS ` ., <br /> II TANK SIZEI0 <br /> L ( FUEL TYPE <br /> 1 11 . GENERAL SITE HISTORY <br /> is permit current? Yes No ( Permit # - Facility Stacus Cade DOC . So1l/GW Cant Yes No <br /> Nu oer of Tanks at facility <br /> ( Age of Tanks ( if available) � ` Type of Tank Steel Fbrgl Sngl Dual <br /> III . TANK HISTORY <br /> Was Tank tested? Yes INc ( Failed precision test ? Yes No lif yes , give dates ) / <br /> Was a repair made to the tank system? es YNo IIf yes , what was repaired? <br /> was repair done under inspection? ( Yes INo Were soil samples analyzed? Yes HeI BTXE TPH-G ( TPH -DlPb/E08 <br /> ) Type of failure/discharge ) catastrophic longterm Leakage overfill <br /> unknown ) other: <br /> IV . REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS ) <br /> Ref/Year <br /> =Average Precipitation <br /> Soil Samples Received Yesl INo Depth to Ground Water lA= 14 10-25 <br /> ( ' <br /> On- Site Welts ) Yes Nol ( Number & Type Irr owl P <br /> S Scare 4 Score S Scare <br /> lls ) frau lank <br /> ft ; ft ; IIIIIIIII�ft C 10 pts C 9 pts C 5fPTS <br /> Distance to We <br /> C if O if <br /> R condition R condition R condition <br /> is met E is t is met <br /> V . Site Feature - Leaching Potential Analysis <br /> me <br /> III am III III <br /> Minimum Depth to groundwater from the Soil Sample ( feet ) <br /> >100 I I51 - 100 I 125 -50\1 <br /> Fractures in subsurface ( applies to foothills or mountain areas ) <br /> None I Unknown ( Present <br /> 10- 25 26-40\2 <br /> Average Annual Precipitation ( inches ) <br /> rocxxxx <10 I 9 Ixxxxxxxl <br /> Man-Made conduits which increase vertical migration I None I I Unknown ( Present <br /> of Leachate 0,e.# septic systems , water wells , Ponds ) <br /> 2 <br /> At Least More than <br /> Unique site features : Recharge area , coarse soil , nearby wells . More one one <br /> J/!J COLUMN TOTALS »TOTAL POINTS <br /> /\. RANGE OF TOTAL POINTS 49 pts ar more I 41 - 48 pts 40 pts or Less <br /> ISanm le Res t : (a T x Da E) Wp �(�, DD6 � <br /> � l lto Im i a— B T X E BT X I E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50I 50 I .3 I .3 1 . I 1 . I NA\3 <br /> _ [p GASOLIN1000 100 10 <br /> E I <br /> aYe�Res � D I i PI+ IMUN ALLOWABLE PHrLEVELS (PPM) l <br /> 100 <br /> 01 ES'cL 101000 l 1000 I <br /> I"_` 3 ` , I, �. CD TPHMO <br /> IrFCOTN�OTES :`�' " * If documented soil and/or ground water contamination is present , do not Colece the leaching potential <br /> np <br /> analysis . ( i . en, site is currently on UGT Cif depth <br /> fest ddornot usertablee.. water . ) <br /> \1 If depth is > 5 ft . and < 25 ft . , score 0 paints. If depth <br /> \2 If precipitation is > 40 inches , score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10cpp�m (gasoline) or 100 ppm (dieseU . <br /> VI . STAFF RECCMMENOATI ON/CONCLUS ICN <br /> xQ cue c 1 G� <br /> 1 . Are BTX & E or TPH concentrations > ALlowable Levels 'Yes No V-w[:J <br /> 2 , Recommend Site Closure Yesl No `If Yes , Refer to Site Mitigation for Evaluation <br /> VII , REVIEW EVALUATION - TO BE COMPLETED Y A SUPERVISOR/SENIOR <br /> liiiiii all I all III all Wall all all � <br /> CONCUR WITH STAFF RECOMMENDATION mamma FOR CLOSUREIYES IND ( REFERRED TO S1TE NITIGATICN FOR EVALUAT IONIYESI IND I <br /> / <br /> DATE CLOSURE LETTER MAILED ( <br /> DATE REFERRED / / / <br /> NAME OF <br /> EVALUATOR <br /> I�ll all all all <br /> -cH 23 80 (UGTWKSHT ) \5/90 <br />