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SAN JOAQUIN % .TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEP,-," DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION GATE a �2 To Z <br /> INANE OF FACILITYfp,Q, 9 p G SWEEPS CODE <br /> ADDRESS <br /> -732 IN $ TANK ID # b r - 3002- <br /> TANK SIZE Cp I Vp FUEL TYPE LIN( 'j -f rk3005 <br /> 11. GENERAL SITE HISTORY <br /> ,Is permit current? Yes I X1No Permit # Q 2 3 - I O Facility Status Code DOC.SOi L/GW Cont Yes No <br /> Nunber of Tanks at facility Z Age of Tanks(if available) 0), Type of Tank Steel FbrgL Sngt Dual k <br /> III. TANK HISTORY <br /> ;Was Tank tested? Yes No Failed precision test ? Yes No [f yes, give date(s) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? [)j J Q/)54r_ 4A/5 <br /> Was repair done under inspection? Yes No HWere soil samples analyzed? Yes x1No BTXE x TPH-G PH-D Pb/EDB <br /> Type of failure/discharge catastrophic lag-tens Leakage overfill Nunknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> !SoiL Samples Received Yes 'x' No Depth to Ground Water 'K Ref/Year 9,1 ; 6fq Average Annual Precipitation A= 14 10-25 <br /> i <br /> On-Site Weit(s) Yes No Number 8 Type Irr Dow Pub <br /> S Score S Score 5 Score <br /> Distance to Well(s) from Tank t{ 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 /> Minimus Depth to groundwater from the Soil Sample (feet) >100 ( 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 1 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> hof leachate (i.e., septic systems, water wells, ponds) None Unknown Present <br /> iUnique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None we one <br /> COLUMN TOTALS»>TOTAL POINTS 0 + Z + S = Z <br /> ;Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pis or more 41 - 48 pts 40 pts or less <br /> B T X E B T X E <br /> • O MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> ;Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> C 1• <br /> TPH 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 sail or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do net 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 8 E or TPH Concentrations > Allowable Levels *Yes X No <br /> 2. Recommend Site Closure Yes No -K *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 ND 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 />