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SAN JOAQUIN COUNTY jBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH D ION DATE 2� <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> I. <br /> SWEEPS CODE 2 <br /> NAME OF FACILITY <br /> TANK ID # <br /> ADDRESS <br /> TANK SIZE FUEL TYPE <br /> II. GENERAL SITE HISTORY *** <br /> Is permit current? Yes No Permit # <br /> Facility Status Code Doc.Soil/GW Cont Yes No <br /> Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> 1 I <br /> Number of Tanks at facility <br /> III. 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] BTXEi TPH-G TPH-D Pb/EDBI <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 <br /> Average Annual Precipitation A= 14 10-25 <br /> On-Site Wells) Yes No Number & Type Irr Dom Pub S Score S Score S Score <br /> C pts C pts C 5 <br /> Distance to Well(S) from Tank ft; ft; ft O f if 0 if O if <br /> pts <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) <br /> >100 i I51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) <br /> None I Unknown 'Present <br /> Average Annual Precipitation (inches) <br /> xxxxxx <10 9 10-25 xxxxxxx26-40\2 <br /> Man-Made conduits which increase vertical migration None Unknown Present <br /> of leachate (i.e., septic systems, water wells, ponds) <br /> 1 At least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None one one <br /> + <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 48 pts 40 pts or less <br /> B T X E B A X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 501 50 .3 �.T <br /> 3 1. 1. NA\3 <br /> GASOLINE 1000 100 10 <br /> Sample Result: <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL 10,000 1000 100 <br /> TPH <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 TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ,CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NOI REFERRED TO SITE MITIGATION FOR EVALUATION YES IND <br /> I <br /> .DATE REFERRED / / <br /> DATE CLOSURE LETTER MAILED <br /> ,NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />