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w <br /> SAN JOAGUIN C. :'�PUSLIC HEALTH SERVICES/ENVIRONMENTAL H& �SIOH <br /> i_ UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE O 1 9 7 <br /> NAME OF FACILITYG s SWEEPS CODE a� <br /> i <br /> I <br /> ADORESS K TANK ID ;* <br /> TANK SIZE A7 0 FUEL TYPE D% Pt il S/1Atjo .S <br /> II. GENERAL SITE HISTORY J" <br /> Is permit current? Yes No Permit N - facility Status Code Doc-Soil/GW Cant Yes No <br /> Number of Tanks at faciEityAge of Tanks(if available} � o Type of Tank Steel Fbrgl Sngl Dual <br /> III. TANK HISTORY �Q <br /> Was Tank tested? Yes No Failed precision test? Yes Hal I If yes,. give date(s) <br /> lWas a repair made to the tank system? Yes No If yes, .what was repaired? <br /> Was repair done under inspection? Yes No Werer-Soil samples analyzed? Yes No BTXE TAH-G{ TPR-0 Pb/EDB <br /> Type of faiLure/dischargeT catastrophic long-term leakage overfill junknowni other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACH ING:POTENT IAL ANALYSIS) <br /> jSoil Samples Received Yes No Depth to Ground Water Ref/Year g Average Annual Precipitation A= 14 .10-25 <br /> On-Site Wetl(s) Yes No Number & Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to Weil(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if O if 0 if <br /> R condition R condition R condition <br /> iv. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> !Minimum Depth to groundwater from the Soil Sample (feet)�G�,- x100 51-100 • 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) ' None Unknown Present <br /> Average Annual Precipitation (inches) xxxx:x <10 9 10-25 Ixwmu= 26-40\2 <br /> Man-Made conduits which increase vertical emigration <br /> of leachate (i.e., septic systems, water welts, ponds) None Unknown I Present <br /> c <br /> Unique site features: Recharge area, coarse soil, nearby sells. � At least) 1More than <br /> xxxxxx Norte 9 ane Il �- one <br /> COLUMN TOTALS»>TOTAL POINTSAAK <br /> + + <br /> !k <br /> S le suit: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts r4G pts or less <br /> 0 � B T X E B TJ.X E <br /> (I <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50� 50 50 .3 1.3 1. 1 NA\3 <br /> Sampte Result: a 1 GASOLINE 1000 100 10 <br />�I,u. 0�7� �Jf ' s IMUN ALLOWABLE TPH LEVELS (PPM) <br /> l TPH d DIESEL 10,000 1000 100 <br /> iOOTXOTES: """If documented sail and/or ground water contamination is present, do not complete the lea i <br /> _ 7 8-0., analysis. (i.e-, site is currently on UGT CohtaO nation List for sail or ground water.) <br /> �1 f depth is > 5 ft. and < 25 ft., score 0 points. If depth —s -ft., do not use table. <br /> \2 If. precipitation is > 40 inches, scare 0 points- <br /> 1 a 3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMEN ATION/CONCLUSION 9.p�l2 �S � 1 l�7 a-.y7�Q <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels "Yes No f �� �� <br /> 2. Recommend Site Closure Yes Na If Yes, Refer to Site.Mitigatian for Evaluation �i51ti�'rJ 5 <br /> coo , i <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FDR EVALUATIONIYES# II <br /> NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> i <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> i r <br />