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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH OIV,- jN IDATEI <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> ' -5 A055 <br /> ` ISUEEPS COOE:2 <br /> NAME OF FACILITY <br /> !TANK ID <br /> 'AO0RESSI <br /> (TANK SIZE FUEL TYPE <br /> iI. GENERAL SITE HISTORY <br /> i <br /> Facility Status Code! IDoc.Soil/GW Cont Yes NO: <br /> is permit current? Yes INo! Permit ! <br /> 'INumcer of Tanks at facility! <br /> Age of Tanks available) Type of TanklSteell IFbrgll Sngli Dua <br /> ( l <br /> III. TANK HISTORY <br /> leas Tank tested? Yes INoi Failed precision test ?lyes INoi, 11f yes, give dates) <br /> i <br /> ;Was a repair made to the tank system?IYesl No If Yes, at was repaired?1 <br /> ',Was repair done under inspection?iYesi lNoi jWere soil samples analyzed? Yes j Noi STXE, <br /> 'TPH-G; TPH-01 IPb/EDB! <br /> (Type of failure/discharge !catastrophic long-term leakage loverfiLll lunknown� )other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> II Average Annua71 <br /> l PrecipitationjA=114 110-25 <br /> SoiL Samples Received Yesl !NoI (Depth to Ground Uaterl Ref/Year) i i <br /> i � I <br /> IOn-Site Wels) Yes No! lNumber & Type! Irrl 1D.1 )Pub <br /> l <br /> 5 Score S Score SScore <br /> Distance to WeLL(s) from Tank ft; ft; ft C 10 pts I C 19 pts 0 ifpts <br /> I O if i 0 if <br /> R condition R (condition) R if <br /> iv. Site Feature - Leaching Potential Analysis <br /> E is met I E ,s met E is met <br /> (Minimum Depth to groundwater from the Soil Sample (feet) <br /> >100 i I51-100 I 1 25-50\1 <br /> lies to foothills or mountain areas) i None I Unknown 1 Present <br /> Fractures in subsurface (app i <br /> Average Annual Precipitation (inches) <br /> xxxxxxl <10 l 9 i 10-25 �xxxx <br /> xxxl 26-40\2 <br /> i�Man-made conduits which increase vertical migration I None Unknown IPresent <br /> Iof leachate (i.e., septic systems, water wells, ponds) <br /> At least) 1More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxxl None I one I one <br /> i <br /> + I I « <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> ( <br /> RANGE OF TOTAL POINTS 49 pts or more 1 41 - 48 pts 1 40 pts or less <br /> Sample Result: (B i X OR E) <br /> B T X E 8 X EMAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1I 50 5c 50 .3 JT <br /> .3 11.1 1. I NA\3 <br /> 10 <br /> Sample Result: GASOLINE 1000 100 .1 <br /> (MAXIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL 10,000 1 1000 100 <br /> I TPH <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not compiete 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 /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable levels *Yesj No I <br /> 2 Recommend Site ClosureiYes INoi 'If Yes, Refer to Site Mitigation for Evaluation! <br /> Vit. REVIEW EVALUATION - TO 3E COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYESI INO! (REFERRED TO SITE .MITIGATION FOR EVALUATIONIYESI jNOI 1 <br /> I <br /> DATE REFERRED( / / DATE CLOSURE LETTER MAILED) <br /> NAME OF I <br /> !EVALUATOR( <br /> i <br /> .H 23 30 (UGTWKSHT)\5/90 <br />