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SAN JOAQUIN COUI 'UBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTI ISION C, <br /> I. <br /> UGSi WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY / - .7.5L �l SWEEPS CODE <br /> i TANK ID # <br /> ADDRESS _� C J �� �(,� f v-C�/� �V CLC <br /> TANK SIZE FUEL TYPE 411� <br /> 1I. GENERAL SITE HISTORY *** <br /> Is permit current? Yes No Permit # Facility Status Code ooc.SoiL/GW Cont Yes INo <br /> Number of Tanks at facility �' Age of Tanks(if available) / Type of Tank Steel Fbrgl ISngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes �tank <br /> Failed precision test ? Yes No If yes, <br /> Was a repair made to thsystem? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil samples analyzed? Yes Nol BTXE TPH-G TPH-0IPb/EDB <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 �S'� Average Annual Precipitation lA= 14 10-25 <br /> On-Site Wells) Yes No Number & Type Irr Dom Pub S 7ScoresScore SScore <br /> Distance to Wells) from Tank lift; ft; ftC 9 pts C 5 pts <br /> 0 if 0 if <br /> ;T1 ` R condition R condition <br /> V. Site Feature - Leaching Potential AnalysisE is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet)1 -C I )100 I51-100 /� 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) I C I 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) �i I None Unknown Present <br /> At least (Mare than <br /> Unique site features: Recharge area, coarse soil, nearby wells. I <br /> xxxxxxl None one � one <br /> CII + = - L <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> Sample Result: (S T X OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 48 pts 40 pts or Less <br /> htkdB T X E 8 T X E \} <br /> i <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1I 50I 50I 50 .3 .3 1. 1. NA\3 I <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) 100 <br /> P <br /> .w DIESEL 10,000 I 1000 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching <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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> 7 ( <br /> V1. STAFF RECOMMENDATION/CONCLUSION f 11 C-L <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yeslr> No � k ��— <br /> a n c. h -v�- <br /> 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation �/� `�� 13�C; <br /> fe <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYES NO (REFERRED TO SITE MITIGATION FOR EVALUATION YES INO <br /> DATE REFERRED L ! / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> ?H 23 80 (UGTWKSHT)\5/90 <br />