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SAN JOAQUIN rY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE F DIVISION <br /> h I UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE 9 <br /> NAME OF FACILITY ! SWEEPS CODE <br /> n ' TANK ID # 3q - 1 (00001 - v3 <br /> ADDRESS <br /> TANK SIZE Z rM CCAII FUEL TYPE Ttk RV <br /> LI , GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit # - Facility Status Code Doc . Soil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks ( if available) uN L Type of Tank SteeL FbrgL SngL Dual <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 /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes No BTXE TPH- G TPH -D Pb <br /> Was <br /> Type of failure/discharge catastrophic long- term leakage 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 5b Ref/Year ; � �3 Average Annual Precipitation A= 14 10- 25 <br /> On- Site We LL ( s ) Yes No Number & Type Irr Doo Pub <br /> 5 Score S Score S Score <br /> Distance to WeIL ( s ) from Tank ft ; ft ; ft C 10 pts C 9 pts C 5 pts <br /> o 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 ) p} >100 51 . 100 5 . 25 - 50\1 <br /> Fractures in subsurface ( applies to foothills or mountain areas ) None C� unknown Present <br /> Average Annual Precipitation ( inches ) xxxxxx <10 9 10- 25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> sof leachate ( i . e . , septic systems , water wells , ponds ) None Unknown Present <br /> Unique site features : Recharge area , coarse soil , nearby wells . At Least More than <br /> r49pts <br /> None Q one one <br /> COLUMN TOTALS»>TOTAL POINTS + S I <br /> S�nple ►+K ( NbX OR E) RANGE OF TOTAL POINTS or more 41 - 48 p 40 pts or Less <br /> 2ifP^ jy ��r� : X E B T X E <br /> � � y5' p}r>l 19PD `1 <br /> I( _ L — 2A wn XIMUM ALLOWABLE B- T-X- E LEVELS (PPM) 1 50 50 50 .3 .3 1 . 1 . NA\3 <br /> Sample Result : GASOLINE 1000 100 10 <br /> jadow — SD�in a AKt)) MAXIMUM ALLOWABLE TPH LEVELS ( PPM ) <br /> ,ul`C DIESEL 10 , 000 1000 100 <br /> FOOTNOTES : *** If documented soil and/or ground water contamination is present , do no a the Leaching potential <br /> analysis . ( i . e. , site is currently an UGT Contamination List for soil or ground water . ) <br /> \1 If depth is > 5 it , 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 BTXBE 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 TPH Concentrations > ALLowable Levels *Yesx No <br /> 2 , Recommend Site Closure Yes No `y * If Yes , Refer to Site Mitigation for Evaluation ) <br /> V ! i . REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> GATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT ) \5/90 <br />