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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVi_ jN IDATEI 2�� ! <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> SWEEPS CCOEi 2 <br /> ,NAME OF FACILITY _ <br /> TANK ID #!i �QS <br /> 'ADDRESS( <br /> 'TANK SIZE( FUEL TYPE I <br /> I, ',"c NERAL SITE HISTORY `** <br /> Is hermit current?1Yes iNol (Permit 4 <br /> Facility Status Codei IDoc.Soil/GW Cont Yesl INoi <br /> INumcer of Tanks at facility <br /> Age of Tanks(if available) IType of Tank SteeLi lFbrgLj ISngl! Dual <br /> ) <br />[II. TANK HISTORY <br /> !Was 'ank tested?lYesl No! Failed precision test ?1Yesi INoi jIf yes, give date s) <br /> ;Was a repair made to the tank system?(Yes, <br /> No �[f yes, what was repaired?� <br /> Was ,-epair done under inspection? Yes l INo! Were soil samples analyzed? Yes! 40 , BTXE! TPH-Gi TPH-01 IPb/EDB; <br /> IType of failure/discharge catastrophic, <br /> (Long-term Leakage (overfill) lunknowni Mother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECii T DATA FOR L'cACHING POTENTIAL ANALYSIS) <br /> (Soil Samples Received Yes! !NoI (Depth to Ground Waterl Ref/Year! <br /> 'Average Annual PrecipitationlA=i14 110-25 <br /> Ilrri 'Dom1 (Pub! <br /> On-Size WeIL(s)1Yes NoI Number d Type! S Score l S Score l S )Score <br /> ft; ft C 110 pts C 9 pts l C 5 pts <br /> ft; <br /> !Distance to WeLL(S) from Tankl I 0 if 0 if <br /> R )condition! R I-onditioni R condition <br /> !V. Site Feature - Leaching Potential Analysis <br /> E lis met I E I s met E lis met <br /> i >1p0 I51-100 I 125-50\1 <br /> (Minimum Depth to groundwater from the Soil Sample (feet) I <br /> (Fractures in subsurface (applies to foothills or mountain areas) <br /> EMone Ei1 Unknown l Present <br /> )Average Annual Precipitation (inches) xxxxx1 10-25 �xxxxxxxi 26-40\2 <br /> Man-Made conduits which increase vertical migration I None I I Unknown 1 !Present <br /> !of leachate (i.e., septic systems, water wells, ponds) <br /> At Leonel More than l <br /> iUnicue site features: Recharge area, coarse soil, nearby wells. xxxxxx) None one <br /> i I <br /> l <br /> - <br /> COLUMN TOTALS—TOTAL POINTS <br /> RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts <br /> E ( 40 pts or less l <br /> )Sample Result: (B T X OR ) ` <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) BI 50l SOI 50 I .3 JT <br /> .3E. <br /> I NA\3 <br /> GASOLINE 1000 <br /> 100 1 10 <br /> ISample Result: 1 <br /> MAXIMUM ALLOWABLE TPH LEVELS CPPM) <br /> 110,000 1000 100 <br /> TPH <br /> l DIESEL <br /> rC0T40TES: <br /> ***If documented soil and/or ground water contamination is present, do not comotete the leaching potential <br /> analysis. l and 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 STME are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> i. Are BTX 3 E or TPH Concentrations > Allowable Levels *Yes) INo <br /> I <br /> Recommend Site ClosurelYesl INo r*If Yes, Refer to Site Mitigation for Evaluation <br /> 2.VII. REVIEW EVALUATION - TO 3E COMPLETED 3Y A SUPERVISOR/SENIOR <br /> iCCNCUR WITH STAFF RECOMMENDATION FOR CLOSUREIYESI IN01, REFERRED TO SITE MITIGATION FOR EVALUATIONIYESI No <br /> ;DATE REFERREDI / / DATE CLOSURE LETTER MAILED! <br /> t <br /> (NAME OF l <br /> 'EVALUATOR( <br /> =H 23 30 (UGT1o4KSHT)\5/90 <br />