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SAN JOAQUIN COe,,. JBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL.rf' ISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME Of FACILITY �G L" SWEEPS COPE <br /> =�Z 3 <br /> ;ADDRESS <br /> TANK ID # C - C� _ <br /> TANK SIZE to G IFUEL TYPE I •fir {L <br /> GENERAL SITE HISTORY <br /> *** <br /> s permit current? Yes No Permit # - Facility Status Code Doc.S�Fb <br /> GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of lank Steel gl Sngl peal <br /> '.I. TANK HISTORY <br /> !Was Tank tested? Yes No Failed precision test ? Yes No If yes, give dates) � /1-1 <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 overfill I unknown other: <br /> 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 Average Arcual Precipitation A= 14 10-25 <br /> On-Site Well(s) Yes No Number & Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to WeLL(S) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) 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) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At Least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS J + -7 + <br /> Sample Reult: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> po <br /> BT X E B T X E <br /> MAXIMUM ALLOWABLE 8-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> ;Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPN DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not 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 /> i. STAFF 2ECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPN Concentrations > Allowabie Levels *Yes No <br /> 2. Recommend Site Closure Yes No If Yes, Refer to Site Mitigation for Evaluation - <br /> .I. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE TES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME Of <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />