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SAN JOAQUIN :. PUBLIC HEALTH SERVICES/ENVIRONMENTAL DIVISION <br /> /I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE �. 7 <br /> i <br /> NAME OF FACILITY SWEEPS CODE <br /> ADDRESS - TANK ID - <br /> D� o <br /> TANK SIZE ,�?Q FUEL TYPf D�' <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit 9 - Facility Status Code Doc.Soit/GW Cant Yes No <br /> Number of Tanks at facility Age.of Tanks(if available) j�& Type of ESteeLINA FbrgL Sngl Dual Lj <br /> Al <br /> III. TANK HISTORY � / <br /> Was Tank tested? Yes . No Failed precision test ? Yes x No If yes, give dates) <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-& TPH-D Pb/EDB <br /> (Type of failure/discharge catastrophic Lang-term leakage lover fiil unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> jSoil Samples Received Yes No Depth to Ground water JV Ref/Year <3(o ; Average Annual Precipitation A= i4 .10-25 <br /> ion-Site Wells) Yes No Number & Type Irr Dom Pub <br /> i S Score S . Score S Score <br /> `Distance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C. 5 pts <br /> 0 if 0 if 0 if <br /> v. Site Feature - Leaching Potential Analysis R condition R. condition R condition <br /> E . is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet)`) 5- >100 51-i00 . 25-50\1 <br /> Fractures in subsurface (applies to foothilts.or mountain areas) J V None Unknown Present <br /> Average Annual Precipitation (inches) V <br /> xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migratiomis} .� <br /> of leachate (i.e., septic systems, water wells pNone Unknown Present <br /> unique site features: Recharge area, coarse soil, nearby wells. At leastj. More than <br /> xxxxxx None one --•_. one <br /> COLUMN TOTALS>>>TOTAL POINTS g + J ni Sample Resuit: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts <br /> rU D _j 0 <br /> EXMAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM} 1 S0 50 50 .3 .3 XSample Result: GASOLINE 1000 i00�� � MAXIMUM ALLOWABLE TPH LEVELS (PPM)TPHD DIESEL 10,000 1000 FOOTNOTES: ***If documented soil and/or ground water contaminations is present, do not complete the L <br /> analysis. (i.e., site is currently an 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 BTX&E 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 ®��w <br /> , <br /> 444 <br /> 2. Recommend Site Closure YesNo If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR ��tr <br /> 43 <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO �r <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILID <br /> i <br /> NAME OF <br /> 1 @VALUATOR -� <br /> EH 23 80 (UGTWKSHT)\5/90 T <br /> !i <br />