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SAN JOAQUIN COUNTY PUBLIC HEALTH ASERVICES/ENVIRICINMENTAL HEALTH tKVISIGN DATE <br /> 1 UGST WORKSHEET FOR EVALUATION •� <br /> SWEEPS CODE a � jS3 <br /> NAME OF FACILITY <br /> ADDRESS <br /> ,SOLO ^ TANK/ItD k 3 <br /> r - I <br /> TANK SIZE FUEL TYPE <br /> PS_ <br /> S <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit # - faCit i 1:11, 1111 Code Q DOC.SOi L/GW Cont Yes No <br /> Number of Tanks at facility <br /> Age of Tanks if available) Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes 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? Yes No Were soil samples analyzed? Yes No BTXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic 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 Water Ref/Year <br /> Average Annual Precipitation A= 14 10-25 <br /> on-Site Welt(s) Yes No Number 8 Type Irr Dom Pub S Score S Score S Score <br /> Distance to Wells) from Tank ft; ft; ft C 10 pts CO 9fPts CO 5fpts <br /> 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) <br /> >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> one, Unknown Present <br /> XXxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Average Annual Precipitation (inches) <br /> Man-Made conduits which increase vertical migration None Unknown Present <br /> of leachate (i.e., septic systems, water watts, ponds) <br /> At least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx Nom one one <br /> 5P t-:r p CA) =.010 X = 0/ 1' Mqj' <br /> ..n9 COLUMN TOTALS»>TOTAL POINTS >IrK 3 <br /> /V40 is or less <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 Pts P <br /> 05A 'r0 'i018_ , 0"t B T X E B T X E <br /> X — •D t I MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 •3 •3 1• 1• MA\3 <br /> Sample Result: s <br /> Q GASOLINE 1000 100 10 <br /> F AX — I <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL 10,000 1000 100 <br /> TPH I <br /> $ esent, do not complete the leeching potential <br /> FOOTNOTES: If documented soil and/or ground water contamination is pr <br /> analysis. (i.e., site is currently on UGT Contamination List for sail or ground water. <br /> \1 If depth is > 5 ft. and < Z5 ft., score 0 points. If depth <=5 ft., do not use table. <br /> \Z If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> ( <br /> VI. STAFF RECOMMENDATION/CONCLUSION P S r r 3 <br /> 5 G -/- <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes No D' n <br /> �) <br /> No 'tf Yes, Refer to Site Mitigation for Evaluation bG_LlinP/`���CI�C-C� , N 11i�. Recommend Site Ct-1.11 7y�: � <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 />