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` SAN JOAQUIN C Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA IVISION <br /> 1 UGST WORKSHEET FOR SITE CLOSURE EVALUATION " DATE <br /> NAME OF FACILITY LoGKZFF4e]�> SWEEPS CODE <br /> 1 <br /> f ADDRESSi �., ��i TANK m # q 23 -6 <br /> TANK SIZE FUEL TYPE C-^1Z, INS <br /> II. GENERAL SITE HISTORY <br /> i Is permit current? Yes No Permit # Facility Status Code Dac.SaiL/GW Cont Yes No ' <br /> I <br /> Number of Tanks at facility Z Age of Tanks(if available) Type of Tank Steel Fbrgl Sngi Dual <br /> III. TANK HISTORY <br /> Was Tank tested? Yes I No Failed precision test ? Yes No If yes, give date(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 anaiyzedl Yes No BTX TPH-G TPH-0 Pb/ED <br /> i <br /> Type of failure/discharge catastrophic long-term leakage overfiLL unknown other: <br /> (V, REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> iSoil Samples ReceivedYes No Depth to Ground Water /� Ref/Tear f��0; Average Annual Precipitation A= 14 10-25 <br /> On-Site Well s) Yes No Number & Type Irr Dam Pub <br /> S Score S Score S Score <br /> (Distance to WeLL(s) from Tank ft; _f t; ft C 10 pts C 9 pts C 5 pts <br /> O if 0 if 0 if <br /> R condition R condition R condition <br /> iv. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> ;Minimum Depth to groundwater from the Soil Sample (feet) )uj�' >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> i <br /> !Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> I <br /> —7 <br /> iMan-Made conduits which increase vertical migration i <br /> Eaf leachate (i.e., septic systems, water wells, ponds) r Q None Unknown Present <br /> iUnique site features: Recharge area, coarse soil, nearby wells. <br /> AL least More than <br /> I XXXxxx None <br /> one one <br /> COLUMN TOTALS>>>TOTAL POINTS Z Q + (l-i- <br /> Sample Result: (B 7 X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B 7 X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> (7 _T PH-C-3 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 /> \2 if precipitation is > 40 inches, score 0 points. ppm p1 (diesel)- <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 (gasoline) or 100 <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > ALLowable Levels 'Yes No <br /> F <br /> 2. Recommend site Closure Yes Na If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YE5 NO i <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />