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JODIVISION SAN JOAQUIN &Y, <br />PUBLIC HEALTH SERVICES/ENVIRONMENTAL <br />1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE8 r..17 7 <br />NAME OF FACILITY / SWEEPS CODE d� r <br />ADDRESS - > TANK ID # - Lj <br />TANK SIZE ,,,.;?D' FUEL TYPE <br />II. GENERAL SITE HISTORY �` 6 <br />s permit current? Yes No ix <br />Permit # - Facility Status Code Doc.SoiI/GW Cont Yes No <br />umber of Tanks at facility Age of Tanks(if available) / /j'to Type of Tank Steel Fbrgl Sngl Dual <br />I-zIII, reuv utcmov ���� <br />Was Tank tested? <br />Yes_ <br />No <br />No <br />Failed precision test ? <br />Yes <br />X' <br />No <br />9(o; <br />If yes, give date(s) <br />A= <br />Was a repair made to the tank system? <br />Yes <br />No <br />Ix <br />If yes, what was repaired? <br />No <br />Was repair done under inspection? <br />Yes <br />No <br />Were soil samples analyzed? Yes <br />Na <br />BTXE <br />TPN -G <br />TPH-D <br />Pb/EDB <br />Type of failure/discharge <br />catastrophic <br />onleakage <br />overfill <br />unknown <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />54 <br />Ll�j' <br />Soil Samples Received <br />Yes <br />No <br />REFERRED TO SITE MITIGATION FOR EVALUATION <br />Depth to Ground Water <br />0 <br />Ref/Year <br />9(o; <br />Average Annual Precipitation <br />A= <br />14 <br />.10-25 <br />Ion -Site Well(S) <br />Yes <br />No <br />iiNumber <br />& Type <br />Irr <br />Dam <br />Pub <br />! <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 <br />ft; ft; ft <br />0 <br />if <br />0 <br />if <br />0 <br />if <br />R <br />E <br />condition <br />is met <br />R <br />E <br />condition <br />is met <br />R <br />E <br />condition <br />is met <br />IV. Site Feature - Leaching Potential Analysis <br />Minimum Depth to groundwater from the Soil Sample (feet) 50 _Ad JL <br />J <br />>100 <br />51-100 <br />r <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 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />Man -Made conduits which increase vertical migration <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 />oneoh <br />---(ne <br />u� � e✓', <br />101 <br />l <br />/0 <br />'3 tT <br />/N COLUMN TOTALS>>>TOTAL POINT <br />* <br />+ <br />- <br />S le suit: (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 />T <br />X <br />E <br />B <br />T <br />X <br />E <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />1 <br />50 <br />50 <br />50 <br />.3 <br />.3 <br />1. <br />I <br />1 <br />NA\3 <br />Sample Result: <br />P a f <br />TPH <br />GASOLINE <br />IMUM ALLOWABLE TPH LEVELS (PPM) <br />DIESEL <br />1000 <br />100 <br />10 <br />10,000 <br />1000 <br />100 <br />nal_ <br />OOTNOTES:*f**If documented soil and/or ground water contamination is present, do not complete the leac ti <br />_ 7 $�dKG�� 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 />e5 \2 If precipitation is > 40 inches, score 0 points. <br />IPX43-Levets for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOMMENKATION/CONCLUSION / + P�'z S Ci 7 7K9 <br />1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No�� <br />2. Recommend Site Closure Yes No 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 <br />YES <br />NO <br />REFERRED TO SITE MITIGATION FOR EVALUATION <br />YESI <br />NO <br />DATE REFERRED <br />/ / <br />DATE CLOSURE LETTER MAILED <br />NAME OF <br />EVALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />