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SAN JOAQUIN COUPTy ''1BLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION 3 <br /> 1. UG 2KSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY ©n l x S4��irS CODE 1199 <br /> ADDRESS 2 0a v V� TANK 10 # - <br /> TANK SIZE FUEL TYPE �}y <br /> 11. GENERAL SITE HISTORY W� ��� 0/ 10r11rT`vl-1-R3 <br /> ttt <br /> Is permit current? Yes No Permit # - Facility Status Code 1191 <br /> Doc.Soi /GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel qFbrgL Sngl1/1 Dual <br /> 111. TANK HISTORY n04 gin a Iq q I <br /> Was Tank tested? Yes No V Failed precision tes ? Yes No I V/ If yes, give date(s)F <br /> /77 <br /> Was a repair made to the tank systemT Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes Were soil samples analyzed? Yes N BTXE TPH-G TPH-0 Pb/EDB <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 Y No Depth to Ground Water ,S Ref/Tear ;9 Average Annual Precipitation _ 14 10-25 <br /> On-Site Wells) Yes No Number & Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to Well(S) 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) >100 51-100 S 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None 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 /> of 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 /> xxxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS ; + . <br /> Sample Result: (S T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> 81 T I X E 8 IT I X E <br /> MAXIMUM 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 /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH 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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are 8TX & E or TPH Concentrations > Allowable Levels *Yes Lill <br /> No <br /> 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation <br /> VII. 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 /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />