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SAN JGAQUIN [XJNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL PH DIVISION <br />1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br />NAME OF FACILITY ' �+ SWEEPS COOEI <br />ADDRESI 3 <br />S- �}� �� TANK [D <br />TANK SIZE ©,0 FUEL TYPE <br />rT GENERAL SITE HIS RY <br />s permit current? Yes No Permit #I - (Facility Status Code IDoc.Soil/GW Cont Yes No <br />umber of Tanks at facility Age of Tanks(if available)( Type of Tank Steell Fbrgl Sngl Oual <br />III. TANK HISTORY <br />Was Tank tested? <br />Yes <br />No <br />No <br />Failed precision test ? <br />Yes <br />Nol If yes, give date(s) <br />14 <br />Was a repair made to the tank system? <br />Yes <br />No <br />IIf yes, what was repaired? <br />Irr <br />Was repair done under inspection? Yes <br />No <br />Were soil samples analyzed? <br />Yes INoI <br />BTXEI ITPH-G TPH-01 Pb/EDB <br />Type of failure/discharge <br />catastrophic <br />long-term Leakage Ioverfill <br />S <br />C <br />unknown Iother: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received Yes <br />No <br />Depth to Ground Water <br />(Ref/Year) <br />Average Annual PrecipitationlA- <br />14 <br />10-25 <br />On -Site Well(S) Yes <br />No <br />Number & Type <br />Irr <br />Dam Publ <br />S <br />C <br />Score <br />10 pts <br />S <br />C <br />Score <br />9 pts <br />S <br />C <br />Score <br />5 pts <br />Distance to Well(S) from Tank ft; ft; ft <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 />0 <br />R <br />E <br />if <br />condition <br />is met <br />V. Site Feature - Leaching Potential Analysis <br />Minimum Depth to groundwater from the Soil Sample (feet) _ -_ <br />>100 <br />( I51-100 <br />` 25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />None <br />I <br />Unknown <br />(Present <br />Average Annual Precipitation (inches) <br />xxxxxx <br /><10 <br />9 110-25 <br />xxxxxxxl <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />I <br />1-5 <br />of leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />Present <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />At least <br />More than <br />xxxxxx <br />None <br />one <br />one <br />10 <br />* <br />+ <br />- .3 <br />41 rJ3 J`= 7-k S COLUMN TOTALT�)TOTAL POINTS <br />V <br />Sample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />41 - 48 pts <br />I 40 pts or less <br />8 <br />x E <br />Pk j T Kl- <br />iM-r.SL <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />B <br />1 <br />T <br />50 <br />X E <br />5050 <br />.3 <br />.3 JT <br />1 <br />1., 1. <br />I <br />NA\3 <br />Sample Result: �fl(( <br />TPH LEVELS (PPM) <br />GASOLINE <br />1000 <br />100 <br />10 <br />DIESEL <br />10,000 <br />1000 <br />100 <br />iQ r1t4/KT TPH IV <br />'7 V <br />MAXIMUM ALLOWABLE <br />FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the teaching po entia <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 J 0/ <br />1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes X Nol �''�A) /6I-) <br />6gq 44-,3 -- G ? xl <br />2. Recommend Site Closure Yes No ` *If Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO SE COMPLETED BY ASUPERVISOR/SENIOR <br />:ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES IND IREFERRED TO SITE MITIGATION FOR EVALUATIONlYES+ INOI <br />ATE REFERRED DATE CLOSURE LETTER MAILEDI <br />AME OF <br />VALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />