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SAN JOAQUIN COUNTY rjoL IC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIV, 'N IDATEI 2 Z/– <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> (SWEEPS CODEi 2 <br /> NAME OF FACILITY <br /> iTANK ID #1 <br /> �ADDRESSj <br /> iTANK SIZE, FUEL TY PEI <br /> I. GENERAL SITE HISTORY '** <br /> lYes INoj (Permit ( iFacility Status Code IDoc.Soil/GW ContlYes <br /> iIs permit current? INoI <br /> Imumber of Tanks at facility <br /> Age of TanksCif available) (Type of Tankisteelj ;Fbrgl� Sngll Dual; l <br /> III. TANK HISTORY <br /> Was Tank tested? Yesl INoi Failed precision test ?(Yes. <br /> 'Noiff yes, give dates) <br /> 'Was a repair made to the tank system?IYesI Noj If yes, what was repaired?I <br /> (Was repair done under inspection?IYesl lNoi iwere soil samples analyzed? Yes) No; 18TXEi TPH-G. <br /> TPN- Pb/EDB! I <br /> (Type of failure/discharge catastrophic long-term leakage) (overfill) lunknownl (other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> I ) (Ref/Year] (Average Annual PrecipitationjA=I14 I10-25 <br /> (Soil Samples ReceivediYesNo Depth to Ground Waterl I P <br /> I i j � I I <br /> ion-Site Well(S) Yes; INoI Number 3 Type �Irrj ID�i !Pub S Score I S (Score I S Score <br /> Distance to Wells) from Tank ft; ft; ft C 10 pts I C 9 pts I C 5fpts <br /> o if I 0 if 0 <br /> R conditions R Icondition� R condition <br /> V. Site Feature Leaching Potential Analysis <br /> "c is met E lis met I E lis met <br /> Minimum Depth to groundwater from the Soil Sample (feet) <br /> >100 i 51-100 i 125-50\1 <br /> FAveErageAnnuaL <br /> subsurface (applies to foothills or mountain areas) <br /> None I Unknown I :Present <br /> Precipitation (inches) <br /> xxxxxxi <10 j 9 10-25 Ixxxxxxx; 26-40\2 <br /> -Made conduits which increase vertical migration I None I Unknown (Present <br /> of leachate (i.e., septic systems, water wells, ponds) <br /> At least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> + <br /> T <br /> RANGE OF TOTAL POINTS 49 pts or more I 41 48 pts I 40 pts or less <br /> Sample Result: (S X OR E) <br /> 3 T X E B T ! X E <br /> MAXIMUM ALLOWABLE B-T X-E LEVELS (PPM) 1) 50 501 50 .3 I.3 I 1-I 1• NA\3 <br /> GASOLINE 1000 100 I 10 <br /> (Sample Result: <br /> MAXIMUM ALLOWABLE TPN LEVELS (PFM) DIESEL 10,000 I 1000 l 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 taole. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are 3TX 3 E or TPH Concentrations > Allowable Levels I*YesI No! <br /> 2 Recommend Site ^losurelYesj INoI *If Yes, Refer to Site Mitigation for Evaluations <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> YES; INoI (REFERRED TO SITE MITIGATION <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREFOR EVALUATICNIYESI INOI <br /> DATE REFERRED( / / <br /> DATE CLOSURE LETTER MAILED( <br /> NAME OF <br /> i <br /> EVALUATOR! <br /> EH 23 80 (UGTWKSHT)\5/90 <br />