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SAN JOAQJ IC HEALTH SERVICES/ENVIRONMENTALLTH DIVISION <br /> DATE <br /> .OU' EVALUATION TE <br /> UGTY =KSHEET FOR SITE CLOSURE , <br /> NAME OF FACILITY SWEEPS COD <br /> ADDRESS TANK _ID #1 <br /> TANK SIZE FUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> is permit current? Yes No Permit iFacility Status Code D Soit/GW Cont Yes Noi <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank I Steel I I Fbrgt I I Snglj Dual L <br /> 111. TANK HISTORY <br /> Was Tank test;d7? Yas No Faitad precision test ?I Yes N07 I If yes, give date(s)) <br /> Was a repair made to the tank system? Yes No if yes, what was repaired? <br /> FW,s repair done under inspection? YesWere soil samples analyzed? Yes No BTXEJ JTPH-Gj ITPH-01 IP <br /> type of failure/discharge catastrophic <br /> 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 WaterL lRef/Year Average Annual Precipitation <br /> on-Site Wells)I Yes No Number & Type Irr Dorn I 1Pub <br /> i S Score S Score S Score <br /> Distance to Well(S) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> a if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E i is met E is met <br /> !Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> ,Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-made conduits which increase vertical migration <br /> of leachate (i.e., septic system, water wells, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby welts. At Least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 48 pts 40 pts or Less <br /> 81 T X1 E 13 [T I X1 E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 1 .3 3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MMIML94 ALLOWABLE TPH LEVELS (PPM) — I <br /> _TPH DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***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. (diesel). <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels I*Yes No <br /> 2. Recommend Site Closure I Yes No I *If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />