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SAN JOAOUIR'COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTALI .ALTH DIVISION <br /> GATE O <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> I. <br /> SWEEPS CODE T <br /> NAME OF FACILITY c�f� TANK 1D # 3 <br /> ADDRESS <br /> TANK SIZE EL TYPE <br /> 11. GENERAL SITE HISTORY <br /> is permit current? Yes No Permit # <br /> facility Status Code Doc.Soil/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 <br /> 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 /> Average Annual Precipitation A= 14 10-25 <br /> Soil Samples Received Yes No Depth to Ground Water Ref/Year <br /> om <br /> On-Site WellIrr DPub <br /> Wells) Yes No Number d Type S Score 5 Score 5 Score <br /> ft; ft C 10 pts C 9 pts U Sfpts <br /> ft; <br /> Distance to WeLL(s) from Tank 0 if O if <br /> R condition R condition R condition <br /> E is met E is met E is met <br /> Y. Site Feature - Leaching Potential Analysis <br /> >100 51-100 25-50\1 <br /> Minimum Depth to groundwater from the Soil Sample (feet) present <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> None Unknown <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 wells, Ponds) <br /> n At Least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None / one one <br /> COLUMN TOTALS»>TOTAL POINTS 111 <br /> Sample Result: (e T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T•X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> GASOII NE 1000 100 10 <br /> Sample Result: 100 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL 10,000 1000 <br /> `_TPH <br /> FOOTNOTES: <br /> •**If documented soil and/or ground water contamination is present, do not complete the teaching potential <br /> analysis. l and/ site is currently on UGT Contamination List for soil or ground water. <br /> \1 if depth is > 5 ft. and < 25 ft., scare 0 points. If depth <=5 f[., do not-use table. <br /> \2 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 Cdiesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 6 E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No <br /> If Yes, Refer to Site Mitigation for Evaluation <br /> 2. Recommend Site=CLsu,]eEN� <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/S NIOR <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 />