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SAN JOAQUIN CCW PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAT! .,,':SION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITY SWEEPS CODE <br /> ADDRESS !70 l�� TANK ID 0 3 <br /> TANK St2E 1�d FUEL TYPE �w <br /> GENERAL SITE HISTORY <br /> �i <br /> Is permit current? Yes No Permit 9 - Facility Status Code �{ Doc.Soit/GLI Cont Yes No <br /> Nrmiber of Tanks at facility Age of Tanks(if available) Type of Tank SteelLl Fbrgl SngL Dust <br /> I. TANK HISTORY <br /> i' <br /> As Tank tested? Yes No Failed precision test ? Yes No If yes,°,'give dates) <br /> was a repair made to th tank system? as No If yes, what was repaired? ,p <br />` dos repair done under inspection? Yes No Were sail samples analyzed? Yes No BTXE TPH-G TPH-D Pb/EDB <br /> Type of faiture/discharge catastrophic long-term leakage overfiLt unknown other: <br /> REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> a <br /> SoiL Samples Received Yes No Depth to Ground Yater 7�p� Ref/Tear �b r Average ArvwaL Precipitation A-114 10-25 <br /> )n-Site Welts) Yes No Number & Type Irr Dam <br /> S scare S Score S Score <br /> )istance to Wett(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if I', i 0 if 0 if <br /> R condition R condition R condition <br /> 1. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> 7inimum Depth to groundwater from the Soil Sampte (feet) 6 >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None ! Unknown Present <br /> leverage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> 4an-Made conduits which increase vertical migration <br /> :)f teachate (i.e., septic systems, water wells, ponds) one Unknown Present <br /> lnique site features: Recharge area, coarse soil, nearby welts. .'i At Least More than <br /> xxxxxx None one ane <br /> COLUMN TOTALS»>TOTAL POINTS 3 + c" _ b <br /> iampl Result• CB T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> - r i.r. .,ro3Pn'' B T x E 8 T X E <br /> odflli�'t MAXIMUM ALLOWABLE B-T-X-E LENSES (PPM) 1 50 50 50 .3 .3 1, 1. NA\3 <br /> Sample Result: + GASOLINE 1000 100 10 <br /> ki.it MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> H\TPH<<D DIESEL 10,000 ' 1000 100 <br /> 0OTNOTES: ***If documented sail and/or ground water contamination is present, do nut 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 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 ppml(gasoLine) or 100 ppm (diesel). <br /> f <br /> STAFF 2ECOMMENOATION/CONCLUSION lL�� <br /> 1. Are BTX & E or TPH Concentrations > ALLowabte LevetsYes No <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for, Evaluation <br /> [. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR :t <br /> i <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION.14OR EVALUATION YES NO <br /> k DATE REFERRED / / DATE CLOSUR L TER MAILED <br /> NAME OF rl/ <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />