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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> i <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> NAME OF FACILITY r / eV��i �j/ 3 SWEEPS CODE 6 <br /> ADDRESS C.L0+/5 ��� �'n v / i^� TANK 22. 1 <br /> ID # / rL <br /> TANK SIZE 3� FUEL TYPE r7767 <br /> 11 . GENERAL SITE HISTORY <br /> Is permit currentt Yes ed No Permit # - Facility StatusCode d Doc . Soi l/GY Cont Yes No <br /> Number of Tanks at facility Age of Tanks( if available) Type of Tank SteeL Fbrgl Sngl Dual <br /> 111 , TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 Yes No If yes , give date( s ) <br /> j 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 unknown other: <br /> IV . REMOVAL HISTORY (ATTACH INSPECTION R PORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS ) <br /> Soil Samples Received YesNo Depth to Ground Water Ref/Year Average Annual Precipitation A= 14 10-25 <br /> On- Site WeLL ( S ) Yes No Number & Type F71rr Dom Pub <br /> 5 Score S Score S Score <br /> Distance to Wells ) from Tank ft; ft ; ft C 10 pts C 9 pts C 5 pts <br /> 0 if O if O 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 5 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 26-411\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 . q At least More than <br /> xxxxxx None / one one <br /> COLUMN TOTALS»>TOTAL POINTS + Z. 7 + = y <br /> Sample Result : ( p T X OR E ) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or Less <br /> B T X E R T X E <br /> MAXIMUM ALLOWABLE Sm LEVELS (PPM) 1 50 50 50 .3 .3 1 . 1 . NA\3 <br /> Sample Rgsul t :s' Lwvo GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPN LEVELS (PPM) WMMMWNMMMW <br /> /ss�� TPH DIESEL 10 , 000 1000 100 <br /> FOOTNOTE If documented soil and/or ground water contamination is present , do not complete the leaching potential <br /> 1' 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 /> 26 <br /> X \3 Levels for BTX&E are not applicable at a TPH concentration of 10 (gasoline) or 100 ppm (diesel ) . <br /> VI RECON[MENDATION/CONCLUSION / <br /> 1 . Are BTX 8 E or TPH Concentrations > Allow le Levels •Yes No � ` 2J�r " v �� <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 /> Ems <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES ✓ NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT ) \5 /90 <br />