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SAN JOAQUIN COUNTLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH ION <br />I, UGS1 KSHEET FOR SITE CLOSURE EVALUATION 1W DATE <br />NAME OF FACILITY h t g -h'") C -k S SQL` �� SWEEPS CODE <br />ADDRESS 9C�q ��� TANK ID # <br />TANK SIZE (2'® FUEL TYPE L((„_ <br />II. GENERAL SITE HISTORY <br />I; <br />*** <br />permit current? Yes / No Permit # - Facility Status Code Doc.Soit/GW Cont Yes No <br />tuber of Tanks at facility C Age of Tanks(if available) Yr" Type of Tank Steel Fbrgl 1XI <br />Sngl Dual <br />TANK HISTORY <br />Was Tank tested? Yes No Failed precision test ? Yes X No If yes, give date(s) <br />Was a repair made to the tank system? Yes No If yes, what was repaired? <br />Was repair done under inspection? YesNo Were soil samples analyzed? Yes No BTXE TPH-G TPH-D Pb/EDB <br />Type of failure/discharge catastrophic long-term leakage overfill unknownother: Linc_ <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received Yes <br />l,,/ <br />No <br />Depth to Ground Water <br />,jC) <br />Ref/Year <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 />Dan <br />✓ <br />Pub <br />S <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 C <br />0 <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 ret <br />R <br />V. Site Feature - Leaching Potential Analysis E <br />Minimum Depth to groundwater from the Soil Sande (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) xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />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 />�� <br />At least <br />More than <br />xxxxxx <br />None <br />one <br />one <br />COLUMN TOTALS>>>TOTAL POINTS 10 <br />+ <br />+ <br />38 <br />Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more <br />41 - 48 pts <br />40 pts or less <br />a7KE �-Ac.l f <br />B T X EB <br />X E <br />l(a ti1MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 50 <br />IT <br />.3 .3 1. 1. <br />NA\3 <br />Sample Result: GASOLINE 1000 <br />100 <br />10 <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />1000 <br />100 <br />N `-D, TPH DIESEL 10,000 <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. <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 *Yes No x <br />2. Recommend Site Closure Yes Ix <br />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 YESNO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br />DATE REFERRED1 DATE CLOSURE LETTER MAILED <br />NAME OF Ur/ <br />r w J� A tip <br />EVALUATOR if <br />EH 23 80 (UGTWKSHT)\5/90 <br />