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SAN JOAQUIN CuuNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA DIVISION <br />I UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br />NAME OF FACILITY e <br />! <br />ADDRESS <br />TANK SIZE �F�UELTYP�E <br />Il. GENERAL SITE HISTORY <br />Is permit current? Yes No <br />Number of Tanks at facility <br />III. TANK HISTORY <br />o z. I SWEEPS CODE <br />(TANK ID #'LID #'L� <br />Permit # PIRI facility Status Code Doc.SOil/GW Cont Yes V N <br />Age of Tanks(if available) Type of Tank Steel' Fbrgl Sngll Dual <br />Was Tank tested? <br />Yes <br />I V1No <br />No <br />Depth to Ground Water <br />Failed precision test ? <br />Yes <br />No <br />A= <br />if yes, give date(s) <br />10-25 <br />Was a repair made to the tank system? <br />Yes <br />No <br />No <br />If yes, what was repaired? <br />Number & Type <br />:las repair done under inspection? <br />Yes <br />No <br />Were soil samples analyzed? <br />l is Yes IN <br />Score <br />10 pts <br />BTXE <br />TPH-G TPH-D <br />S <br />C <br />Pb/EDB <br />Type of failure/discharge <br />catastrophic <br />long-term leakage <br />overfill unknown <br />if <br />condition <br />is met <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FUK LtALn1NU ruiCniinL. A -1 —J <br />Soil Samples Received <br />Yes <br />No <br />Depth to Ground Water <br />Ref/Year N �; <br />Average Annual Precipitation <br />A= <br />14 <br />10-25 <br />On -Site Wells) <br />Yes <br />No <br />Number & Type <br />Irr <br />Dom <br />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 Wells) from Tank <br />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 />51-100 <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />Present <br />Average Annual Precipitation (inches) <br />xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />!Man -Made conduits which increase vertical migration <br />Unknown <br />Present <br />jof leachate (i.e., septic systems, water wells, ponds) <br />None <br />;Unique site features: Recharge area, coarse soil, nearby wells. <br />At least) <br />one <br />More than <br />one <br />xxxxxx <br />None <br />++ <br />- <br />COLUMN TOTALS»>TOTAL POINTS <br />;Sample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />41 - 48 pts <br />40 pts or less <br />B <br />7 <br />X <br />E <br />8 <br />X <br />E <br />i <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />1 <br />50 <br />50 <br />50 <br />.3 <br />JT <br />.3 <br />1. <br />1. <br />NA\3 <br />.Sample Result:�' <br />GASOLINE <br />1000 <br />100 <br />10 <br />ZZ TPH <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />DIESEL <br />10,000 <br />1000 <br />�00 <br />FOOTNOTES: ***If documented soil and/or ground water contamination 1s present, as nay cW 4,._�_ �•_ •_��•••••= r--- - - <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 BTX & E or TPH Concentrations > Allowable Levels *YesF I <br />No <br />2. Recommend Site Closure Yes V/jNo If Yes, Refer to Site Mitigation forEvaluation <br />V.I cveinnTTMI - TM cc rnND1FTFn RY A Sl1PF2V1S0R/SENI0R <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES <br />DATE REFERRED / / DATE CLOSURE LETTER MAILED <br />NAME OF �J�I.� itil <br />(EVALUATOR N <br />EH 23 80 (UGTWKSHT)\5/90 i <br />