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SAN JOAQI�OUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL%.TH DIVISION 8� �� <br /> I. -; UGST WORKSHEET FOR SITE CLOSURE EVALUATIOi., .- DATE �0rn -I- <br /> NAME OF FACILITYl Q O CG <br /> D6' SWEEPS CODE r <br /> ADDRESS t J�� �. JL. �� TANK 10 `'i 39 - t3Z6 - Oz <br /> TANK SIZE boo FUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Yes Ho Permit #i Facility Status Code Occ.SaiL/GW Cant Yes No <br /> Humber of Tanks at facility Age of Tanks(if available uy Type of Tank Steel Fbrgl SngEl Oual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes No )( Failed precision test ? Yes I No If yes, giveda=e(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 a lyzed? Yes VINQ BTXE TPN-G TPH-0 j VfPb/Eo* <br /> Type of failure/discharge catastrophic Long-term Leakage OVIRrfil! X unknown other• tr1 ° ter+ "L <br /> ell <br /> 1�b <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEA CHI ENTIAL ANALYSIS) <br /> SoiL Samples Received Yes 'x Na Depth to Ground Water '"l Ref/Y ar Ct5 Average Annual Precipitation A= 14 10-25 <br /> On-Site WeLL(s) Yes "r,, T,,k <br /> Number & Type X Irr Dom Pub <br /> S Score S Scare S Score <br /> Distance to WeIL(s) Z Q ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 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 I51-100125-501 <br /> Fractures in subsurface (applies to foothills or mountain areas) ( None Unknown Present <br /> Average Annual Precipitation (inches) xxx)xxx <10 9 10-25 xxxxxxx� 26-40\2 <br /> Man-Made conduits which increase vertical migration _ <br /> of leachate (i.e., septic systems, water weELs, ponds) None Unknown 5 Present <br /> Unique site features: Recharge area, coarse soil, nearby welts. I At Least More than <br /> xxxxxx None Q one one <br /> COLUMN TOTALS>>>TOTAL POINTS `0 + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINT 49 pts or more 41 - 48 pts 40 pts or Less <br /> N !I G 4� G I TMUM ALLOWABLE B-F-x-E LEVELS (PPM 50 50 50 .3 .3 1. E NA\3 <br /> Samp a Result-_ GASOLIN 1000 100 10 <br /> CsO"S MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 82 0C)'_- TPH DIESEL 10,000 1000 100 <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., scare 0 points. If depth (=5 ft., do not use table. <br /> 12 if precipitation is > 40 inches, score 0 points. <br /> 13 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 *Yes N <br /> 2. Recommend Site CYes No If Yes, Refer to Site Mitigation for Evaluation <br /> losure <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED ro SITE MITIGATION FOR EVALUATION YES N0I <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />