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SAN JOAQUIN Ct? 'PUSLIC HEALTH SERVICES/ENVIRONMENTAL HEAD%,. VI5lON <br /> E. <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE g p <br /> NAME OF FACILITYi SWEEPS CODE <br /> ADDRESS TANK ID 9 <br /> �� <br /> TANK SIZE j FUEL TYPE <br /> I1. GENERAL SITE HISTORY *** <br /> lis permit curre�YesNo Permit # - Facility Status Code Doc.Soi[/GW Cont ResqNumber of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sng <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-GI TPH-D Pb/ED8 <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 Vater j Ref/ ear ; Average Annual Precipitation A= 14 -25 <br /> 7 <br /> On-site Wells) Yes No Number & Type Irr Dom Pub. <br /> S Score S Score Score <br /> Distance to Wells) from Tank ft; ft; ft C 10 pt 9 pts C 5 pts <br /> 0 if if 0 if <br /> R condi nV'C <br /> R ition R condition <br /> V. Site Feature Leaching Potential Analysis E s E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) 100 51-100 25150\1 <br /> Fractures in subsurface (applies to foothills or mount in are s) one Unknown Present <br /> xx <10 9 10-25 xxxxxxx 26-40\2 <br /> Average Annual Precipitation (inches) <br /> Man-made conduits which increase vertical a i None Unknown Present <br /> of leachate (i.e., septic systems, water well s) <br /> At least More than <br /> Unique site features: Recharge rea, co rse oil arby wells. xxxxxx None one one <br /> OL ALS> OTAL POINTS + + <br /> Sample Result: (B T X R RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> BI T I X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E.LEVELS' (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Re t: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: IV ***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. ppm (diesel). <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 <br /> V1. STAFF RECOMMENDATION/CONCLUSION fJ}�{ <br /> > Lowable Levels *Yes No �0 t �` l� <br /> 1. Are BTX & E or TPH Concentrations Al V <br /> u <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/5 OR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YE5 NO <br /> DATE REFERRED DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />