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SAN JOAQUIW kr ;Y PUBLIC HEALTH SERVICES/ENVIRCNMENTAL hv.," o'DIVISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> Of FACILITY _ _ <br /> DATE <br /> J � j.7— <br /> SWEEPS CODE <br /> �ORESSI <br /> TANK SIZE / y' 1TANK IO # <br /> FUEL TYPE <br /> GENERAL SITE HISTORY <br /> Is permit current?+Yes No Permit # - *** <br /> Facility Status Code Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) I <br /> Type of Tank Steel Fbrgl Sngl Dual <br /> :II. TANK HISTORY <br /> [Was Tank tested? Yes No [Failed precision test ? Yes No If yes, give date(s) // <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-G (TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfillunknown other: <br /> :Y. 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 - <br /> Average Annual Precipitation A= 14 10-25 <br /> ,On-Site WeIL(S) Yes xNo Number & Type Irr Doml Pub <br /> Distance to WeLL(s) frac lank rJ(� ft• ft. S Score S Score S Score <br /> 11--___ ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> V. Site Feature R condition R condition R condition leaching Potential Analysis E is met 'c is met E is met <br /> ,Minimum Depth to groundwater from the Soil Sample (feet) 1'D >100 51-100 I 125-50\1 <br /> ifractures in subsurface (applies to foothills or mountain areas) None I q 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) None <br /> Unknown Present <br /> `Unique site features: Recharge area, coarse soil, nearby wells. None oI At LeMore More than <br /> xxxxxx ne one <br /> COLUMN TOTALS»>TOTAL POINTS ; J-� 7 + _ <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48_pts I 40 pts or less <br /> kr B T X E 8 7 X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1i 50I SOI 50 (.3 1. 11 NA\3 <br /> Sample Result: ft(3-0 GASOLINE 1000 i 100 �j � 10 <br /> C Do 0 H MAXIMUM ALLOWABLE TPH <br /> �VEL•S <br /> >� k! - 7�H =,/(pC yyl JESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or gr wa er contamination is present, dot complete-the leaching potential <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 /> II. STAFF tECOMUIENDATION/CONCLUSION � / �.�✓ �1 SC ibS-(y ,�LL9J`Z <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels 'Yes No YIc�`t"�'�`-✓ �� <br /> 2. Recommend Site Ctosure Yes No If Yes, Refer to Site Mitigation for Evaluation <br /> III. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES ' NO REFERRED TO SITE MITIGATION FOR EVALUATION TES NOI <br /> DATE REFERRED / / ATE CLOSURE LETTER MAILED / / <br /> NAME OF <br /> EVALUATOR I <br /> EH 23 80 (UGTWKSHT)\5/90 <br />