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' M <br /> SAN JOAQUIV.NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL ,H DIVISION <br /> [. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> NAME OF FACILITYr' YlBP <br /> SWEEPS CODE I <br /> :ADDRESS TANK ID # <br /> TANK SIZE DO h FUEL TYPE <br /> :I. GENERAL SITE HISTORY <br /> *,r,e <br /> Is permit current? Yes No Permit # - Facility Status Code Ooc.Soil/GW Cont Yes No <br /> :Number of Tanks at facility Age of Tanks(if avaiLable) Type of Tank Steel Fbrg[ Sngl Dual <br /> 111. TANK HISTORY <br /> :Was Tank tested? Yes No Fafled precision test ? Yes No if yes, give date(-) <br /> 'Was a repair made to the tank system? Yes No' If yes, what was repaired? <br /> .as repair done under inspection? Yes No Were soil samples analyzed?I Yes No BTXE TPH-G TPH-D Pb/EDB <br /> ,Type of failure/discharge catastrophic Long-term leakage overfill unknown other: <br /> i <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA.FOR LEACHING POTENTIAL ANALYSIS) <br /> !Soil Sa les Received Yes No Depth to Ground Water Ref/Tear Average Annual Precipitation A= 14 10-25 <br /> mR P <br /> On-Site Well(s) Yes No Number & Type Irr Dom !Pub <br /> S Score 5 Score 'S Score <br /> -stance to Weil(s) from Tank 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 - teaching Potential Analysis E is met E is met E is met <br /> :Minimum Depth to groundwater from the Sail Sample (feet) >100 I 51-100 25-50\1 i <br /> Fractures in subsurface (applies to foothills or'-mountain areas) None Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\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. At Least More than <br /> xxxxxx None one one <br /> TIXS _= fel! IV U 6TEX _ <br /> 17OLUMN TOTALS>>>TOTAL POINTS + <br /> Sample Result: (B T X OR E) K RANGE OF TOTAL POINTS 49 pts or more I 41 - 48 pts 40 pts or less <br /> �-sCi�l3. H TSG -J,t�� B T X E B X ; EMAXIMUM ALLOWABLE B-T=X-E LEVELS (PPM) 1 50 50 50 .3 <br /> J.T <br /> 3 1.� 1. NA\3 <br /> 'Sams a Resu t• GASOLINE 1000 100 10 / <br /> TaJl Ni MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> , S _TPH G7 DIESEL 10,000 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the le <br /> analysis. (i.e., site.is currently on UGT Contamination List for soil or. grotnid 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 applicabie at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> 7I. STAFF RECOMMENDATION/CONCLUSION <br /> I <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation <br /> I <br /> IT3. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES( NOI (REFERRED TO SITE MITIGATION FOR EVALUATION TES NOI <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED( / / € <br /> ;NAME OF I <br /> }EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />