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SAN JOAQUIN COWfY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL+. DIVISION �/' <br />I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE T— <br />(NAME OF FACILITY `T )n_ O/aI7 //A?(SWEEPS CODE( <br />(ADDRESS ')S / % Dn , ea-iA ,. �� 0_Q v ri C—s74^ lrll v - ITANK ID 991 r. <br />(TANK SIZE( 560 IFUEL TYPE( <br />r %'Lf/ G�il'G7 <br />ii. GENERAL SITE HISTORY <br />is permit current? <br />Yes <br />No <br />No <br />Depth to Ground Water <br />Permit X <br />Ref/Year <br />Facility Status Code <br />No <br />IIf <br />Doc.Soi l/GW Cont <br />Yes <br />Was a repair made to the tank system? <br />No <br />No <br />Nunoer of Tanks at facility) <br />If yes, what was repaired? <br />Age of Tanks(if available) <br />Was repair done under inspection?(Yes <br />IType of Tank <br />Steel <br />Dom <br />Fbrgl <br />Yes <br />Sngl <br />Dual <br />S <br />C <br />0 <br />R <br />E <br />111. TANK HISTORY <br />Was Tank tested? <br />Yes <br />No <br />No <br />Depth to Ground Water <br />Failed precision test ?(Yes <br />Ref/Year <br />No <br />IIf <br />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 />Nmmber & Type <br />Was repair done under inspection?(Yes <br />Irr <br />No <br />Dom <br />(Were soil samples analyzed? <br />Yes <br />S <br />C <br />0 <br />R <br />E <br />Na <br />S <br />C <br />0 <br />R <br />E <br />BTXE <br />TPH -G <br />TPH-01 <br />Pb/EDB <br />ft; ft; ft <br />Type of failure/discharge <br />V. Site Feature - Leaching Potential Analysis <br />catastrophic <br />long-term leakage <br />overfill <br />unknown <br />Fractures in subsurface (applies to foothills or mountain areas) <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received Yes <br />YES <br />No <br />NO <br />Depth to Ground Water <br />YES <br />Ref/Year <br />Average Annual Precipitation <br />A= <br />14 <br />10-25 <br />On -Site Wells) <br />Yes <br />NAME OF <br />EVALUATOR <br />No <br />Nmmber & Type <br />Irr <br />Dom <br />Pub <br />S <br />C <br />0 <br />R <br />E <br />Score <br />10 pis <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />9 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />5 pis <br />if <br />condition <br />is met <br />Distance to Well(:) from Tank <br />ft; ft; ft <br />V. Site Feature - Leaching Potential Analysis <br />Mini mm 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 />xxxxxXl <br /><10 <br />9 <br />110-25 <br />xxxxxxx <br />26-40\2 <br />Man -Made conduits which increase vemical 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 />xxxzxX <br />None <br />At least <br />one <br />More than <br />one <br />COLUMN TOTALS»>TOTAL POINTS <br />+ <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 />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />B <br />1 <br />T <br />50 <br />X <br />50 <br />E <br />50 <br />B <br />.3 <br />T X <br />.3 1. <br />E <br />1. <br />NA\3 <br />Sample Result: GASOLINE <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />TPH DIESEL <br />1000 <br />100 <br />10 <br />10,000 <br />1000 <br />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. <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 TPN 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 />YES <br />NO <br />DATE REFERRED <br />/ / <br />DATE CLOSURE LETTER MAILED <br />NAME OF <br />EVALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />