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SAN JOAQ01 NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL 1W DIVISION <br />I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE — <br />NAME OF FACILITY I / "� SWEEPS CODE <br />ADDRESS TANK IO #13 <br />- <br />TANK SIZEDOC)FUEL TYPE r <br />R - GFNFRAL SITE HIST Y <br />�xs <br />s permit current? Yes No Permit # - PFacility Status Code �Doc.Soit/GW Cant Yes !No <br />umber of Tanks at facilityAge of Tanks(if available) Type of Tank Steel Fbrgl Sngl Oual <br />III. TANK HISTORY <br />Was Tank tested? <br />Yes <br />No <br />No Failed precision test ? <br />Yes <br />!Ref/Y <br />No1 If yes, give dates) <br />Average Annual Precipitation <br />Was a repair made to the tank system? <br />Yes <br />No <br />If yes, what was repaired? <br />Was repair don under inspection? <br />Yes <br />Numlber & Type <br />No <br />Irr <br />Were soil samples analyzed? <br />Yes I XO <br />RTXEr TPH-G <br />TPH-0 <br />Pb/EDB <br />Type of failure/discharge <br />catastrophic <br />Long-term leakage overfill <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OETAILS/COLLECT DATAP6R LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received 1Yes <br />No <br />Depth to Ground Water <br />!Ref/Y <br />; <br />Average Annual Precipitation <br />A= <br />14 <br />10-25 <br />On -Site Well(S) Yes <br />No <br />Numlber & Type <br />Irr <br />Dom <br />ub <br />S <br />Score <br />10 pts <br />S <br />C <br />Stere <br />9 pts <br />S <br />C <br />Scare <br />5 pts <br />Distance to Wetl(s) from Tank ft; ft; ft C <br />0 <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />R <br />v. Site Feature - Leaching Potential AnalysU E <br />Minimum Depth to groundwater from the Soil Samol6,( t) "�j r- <br />>100 <br />51-100 <br />25-50\1 <br />Fractures in subsurface (applies to foothills or ''`fain area ) <br />None <br />P I <br />Unknown <br />(Present <br />Average Annual Precipitation Orr hes) xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />Man -Made conduits which increase vertical sgration �'N <br />None <br />Unknown <br />iPresent <br />of leachate (i.e., septic system water its, ponds) <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />At least <br />More than <br />xxxxxx <br />Nose <br />one <br />one <br />TOT S»>TOTAL POINTS j <br />* <br />COLUMN <br />Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 44�tpts or more <br />41 - 48 pts <br />or <br />'r �✓ X E <br />B <br />X <br />E <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 5 50� 50 <br />.3 <br />JT <br />.3 <br />1. <br />1. <br />NA\3 <br />Sample Result: <br />SIAM ALLOWABLE TPH LEVELS (PPM) <br />GASOLINE 100 <br />100 <br />10 <br />® TPN <br />DIESEL 10,000 <br />1000 <br />100 <br />FOOTNOTES:*** f documented soil and/or ground water contaminatiochn is present,.do riot complete the lea <br />analysis. (i.e., site is currently on UGT Contamination Li for sail or ground water.) <br />\ If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br />If precipitation is > 40 inches, score 0 points. <br />3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm asotine) or 100 ppm (diesel). <br />VI. STAFF RECOMME ATION/CONCLUSION <br />1. Are BTX & E or TPH Concentrations > Atlowabte Levels *Yes No , f <br />2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation y.._ <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />YA <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO 1 <br />DATE REFERREDI / / DATE CLOSURE LETTER MAILEDI <br />NAME OF <br />EVALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />