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SAN JOAQUIN M ,/PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL! `,iiISION <br /> I' UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATEI <br /> NAME OF FACILITY 1 JAS` =� a <br /> ��—i—� / �v� SWEEPS CODE <br /> ADDRESS -3-3c:;, .�—�G Ai< G� TANK ID 9 <br /> TANK SIZE( fZ,� FUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Yes 7 No Permit # - Facility Status Code Doc.SoiL/GW Cant Yes No <br /> Number of Tanks at facility Age of Tanks(if avaitabit Type of Tank Steell Fbrgll SngL Oual <br /> III. TANK HISTORY <br /> Fs Tank tested? Yes No Failed precision test ? Yes No If yes, give dates)a repair made to the tank system? Yes NoI If yes, what was repaired? <br /> Was repair done under inspection?lYes �No Were soil samples analyzed? Yes Nol BTXEi (TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakagel overfill unknown 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 q5 Ref/YeaAverage Annual PrecipitationA=I 14 10-25 <br /> On-Site Wells) Yes No Number 3 Type Irr Dom Pub <br /> S Score S Score 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 /> Minimum Depth to groundwater from the Soil Sample (feet) G / i >100 i 51-100 S 25-50\1 <br /> Fractures in subsurface (applies to foothiLts or mountain areas) i None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxxl <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknown I Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS>>TOTAL POINTS <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more I ( 41 48 p s I 40 pts or Less <br /> n = nl.a•. . v�•S E=�•d- <br /> -/_ B TX E B" E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 10 10 50 50 .3 13 1 1. 1. I NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE 7PH LEVELS (PPM) <br /> DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the 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 /> \3 Levels for 3TX8E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPN Concentrations > Allowable Levels *YesNo i <br /> 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for 'cvatuatian <br /> x <br /> VII. REVIEW EVALUATION - 70 BE COMPLETED BY A SUPERVISOR/SENIOR <br /> 3 <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATIONIYES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />