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SAN JOAQUIN COUELIC HEALTH SERVICES/ENVIRONMENTAL HEALT SION <br /> 1. UGS ORKSHEET FOR SITE CLOSURE EVALUATION DATE S— <br /> NAME OF FACILITY �- /IISWEEPS CODE a3/3 <br /> ADDRESS osa-;, TANK ID <br /> TANK SIZE /0 QQ0 FUEL TYPE "cerci <br /> 11. GENERAL SITE HISTORY <br /> k** <br /> Is permit current? Yes Na 15 <br /> Per k - Facility Status Code DOc.S011/GW Cant Yes No X <br /> Number of Tanks at facility Age of Tanks(if available) la Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 Yes No X If yes, give date(s) **Ot Was a repair made to the tank system? Yes No If yes, what was repaired? G��✓Was repair done under inspection? Yes No Nere soil samples analyzed? Yes No BTXE ` <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 Average Annual Precipitation A= 14 10-25 <br /> On-Site Well(s) Yes No Number 8 Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to Well( from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 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) — 4 = >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) / 6 None Unknown Present <br /> Average Annual Precipitation (inches) XXXxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) 0 None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS �y(� / g 0 = 3 <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts pts or les <br /> P Tx—� <br /> d' i. ' N D B T X E a T X E <br /> 5 MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 ..3 1. 1. MA\3 <br /> Sample Result_ GASOLINE 1000 100 10 <br /> TK 5 W.4 t ° DMAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH L DIESEL 10,000 1000 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 STXBE 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 <br /> 2. Recommend Site CLosurelYes INoj F*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 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 />