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_1� <br />SAN JOAQUINuZ.1NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HA DIVISION Cj <br />1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE a '— <br />NAME OF FACILITY SWEEPS CODE <br />,ADDRESS 0 3 r TANK LD #� - j5-76 <br />__ <br />,TANK SIZE �D FUEL TYPE 0,',V1O <br />(l. GENERAL SITE HISTORY <br />rrr <br />Is permit current? Yes No Permit # - Facility Status Code Doc.Soit/GWCont Yes No <br />!Number of Tanks at facility Age of Tanks(if available) li,,kk Type of Tank Steel FbrgL Sngl Dual <br />II1. TANK HISTORY <br />Was Tank tested? <br />Yes <br />1>QNo <br />No <br />NO <br />Failed precision test ? <br />Yes <br />Ref/Year <br />No <br />If yes, give date(s) <br />A=114 <br />Was a repair made to the tank system? <br />Yes <br />No <br />Yes <br />If yes, what was repaired? <br />No <br />,:as repair done under inspection? <br />Yes <br />No <br />Were soil samples analyzed? Yes <br />No <br />S <br />C <br />0 <br />R <br />E <br />BTXE <br />TPH-G <br />Score <br />9 pts <br />if <br />condition <br />is met <br />TPH-D <br />Score <br />5 pts <br />if <br />condition <br />is met <br />Pb/EDB <br />ft; ft; ft <br />Type of failure/discharge <br />IV. Site Feature . Leaching Potential Analysis <br />catastrophic <br />long-term leakage <br />overfilLl <br />unknown <br />25-50\1 <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />'Soil Samples ReceivediYesi <br />RECOMMENDATION FOR CLOSURE <br />YES <br />No <br />NO <br />Depth to Ground Water <br />YES <br />Ref/Year <br />NO <br />Average Annual Precipitation <br />A=114 <br />DATE REFERRED <br />10-25 <br />jOn-Site Wells) <br />Yes <br />CLOSURE LETTER MAILEDI <br />No <br />NAME OF <br />EVALUATOR <br />Number 8 Type <br />Irr <br />Dan <br />IPub <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 />5 <br />C <br />0 <br />R <br />E <br />Score <br />5 pts <br />if <br />condition <br />is met <br />D+stance to Wells) from Tank <br />ft; ft; ft <br />IV. Site Feature . Leaching Potential Analysis <br />Minimm Depth to groundwater from the Soil Sade (feet) sq� <br />>100 <br />51-100 <br />25-50\1 <br />.Fractures in subsurface (applies to foothills or mountain areas) <br />I c) <br />None <br />Unknown <br />Present <br />'.Average Annual Precipitation (inches) <br />xxxaxx <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 />5 <br />Present <br />;Unique site features: Recharge area, coarse soil, nearby wells. <br />Ip <br />xxxxxx <br />None <br />At least <br />ane <br />More than <br />one <br />�Kss = Uir..X <br />COLUMN TOTALS»>TOTAL POINTS <br />j <br />l p <br />) 8 <br />/ O <br />_ 3 <br />'SamoLq Result: (B T XX OR E) <br />�3—B* (� Ir,6q <br />RANGE <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />41 - 48 pts <br />MAXIMUM ALLOWABLE S -T -X -E LEVELS (PPM) <br />B T <br />1 50 <br />% <br />50 <br />E <br />50 <br />8 <br />.3 <br />T <br />.3 <br />% E4 <br />1.I 1 <br />OF <br />NA\3 <br />3L Result• <br />I v. K <br />K'21, A) ' ' + 10TPH D <br />GASOLINE <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) 1 <br />DIESEL <br />1000 <br />100 <br />1 <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 lea <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 STX8E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />'11. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX 8 E or TPH Concentrations > Allowable Levels *Yesx No <br />2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evat <br />/II. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />!CONCUR WITH STAFF <br />RECOMMENDATION FOR CLOSURE <br />YES <br />NO <br />REFERRED TO SITE MITIGATION FOR EVALUATION <br />YES <br />NO <br />DATE REFERRED <br />/ / <br />DATE <br />CLOSURE LETTER MAILEDI <br />NAME OF <br />EVALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />