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SAN JOAQUOUNTY PUBLIC HEALTH SERVICES/ENVIRONMEMTAL &H DIVISION <br />t UGST WORKSHEET FOR SITE CLOSURE EVALUATION OATEI7-32- <br />NAME <br />—2-NAME OF FAC I L I TY / - f - i �c. SWEEPS CODE j 3 i 7" <br />ADDRESS ` a G (TANK ID #f <br />TANK SIZE 104&&V FUEL TYPE <br />II. GENERAL SITE HISTORY <br />s permit current? IYes I �go IPermitI - ,Facility Status Code IDoc.Soil/GW Conc Yes IN®I <br />umber of Tanks at facilityl IAge of Tanks(if availabtefl Type of TanklSteell Fbrgt ISngtl Ouall <br />III. TANK HISTORY <br />Was Tank tested? Yes <br />No <br />No Faited precision test ? <br />Yesl No Iif yes, give dates) <br />(In -Site Well(s)IYes INo Number b Type Irr DomlPeal <br />Was a repair ;trade to the tank system? I Yes i No I If yes, what uas repaired? <br />was repair done under inspection? Yes ING1 Were soil samples analyzed? Yes INoI <br />BTXEi }TPR -GI TPN -fl 'jPb/EDB <br />Type of failure/discharge <br />catastrophic long-term leakagel Iveirf %llI eunknownl 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 IRef/Year IAverage Annuat PrecipitatiotlAz- <br />14 10-25 <br />(In -Site Well(s)IYes INo Number b Type Irr DomlPeal <br />S <br />Scare <br />10 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />Scores <br />9 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />5 pts <br />if <br />condition <br />is met <br />Distance to Wells) from Tank ft; ft; ft C <br />0 <br />R <br />V. Site Feature - Leaching Potential Analysis E <br />Minimum Depth to groundwater from the Soil Samote (feet) <br />i >100 <br />1 <br />151-100 <br />I <br />i 25-5010 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />I Yate <br />I <br />p Unknown <br />I <br />IPresent <br />Average Annual Precipitation (inches) 1x==1 <br /><10 <br />! 9 <br />4 10-5 <br />j=Co=j26-4442 <br />1 <br />Man -Made conduits which increase Vertical migration <br />�of leachate (i.e., septic st , water wells, ,ponds) <br />ys <br />� None <br />, Unknwn o <br />� <br />Present <br />; <br />Unique site features: Recharge area, coarse soil, nearby wet Ls- <br />)000= <br />None <br />i <br />I At least! <br />one <br />!fie than <br />j -rK,3 S= 1 ®t 4 <br />]]]] COLtRN IOTA > 07AL POI NTS <br />Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more <br />�� Al <br />IVC MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 11 501 501 50 <br />I 61 - 4a pts <br />I 40 pts or less <br />3 J.3 1.� 1. <br />{ NA\3 <br />S R ult: Gyfi� <br />TPM <br />GASOLINE 1000 <br />14AX114M ALLOWABLE TPH LEVELS (PPM) <br />DIESEL. 10,000 <br />100 <br />10 <br />1000 <br />I too <br />FOOTNOTES: **"If documented soil and/or ground water contamination is present, do not complete the teaching 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 STXBE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (dieset). <br />VI. STAFF RECOMMENDATION/CONCLUSION ��VV <br />1. Are BTX 3 ° or TPH Concentrations > Allowable Levels �*Yesl !No4 `t) �p <br />( <br />. Recommend Site Clossure}Yesl Noq *If Yes, Refer to Site Mitigation for _vatuation <br />16-11 <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIiR <br />C'MCUR WITH STAFF RECOMMENDATION FOR CLOSUREJYESI 'NO! IREFEtRED TO SITE MITIGATION FOR EVALUATIONIYESj iNOI I <br />DATE REFERRED i / / ;DATE CLOSURE LETM MAILM- 1 / ! <br />NAME OF <br />EVALUATOR <br />_H 23 30 (UGTWKSHT)\5/90 <br />