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SAN JOAQUIN C. :PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE,t. DIVISION <br /> I, UGST WORKSHEET FOR SITE CL05URE'EVALUATION DATE 7 ! '53 <br /> NAME OF FACILITY �i � ���, SWEEPS CODE <br /> i 1 �2 TANK 1D <br /> ADDRESS I <br /> l 1 J b CIV, <br /> ` p <br /> TANK SIZE 2 �a� e-A FUEL TYPE TAAV it, 4- �4 D j Z 0-2— <br /> 11. GENERAL SITE HISTORY 2 pr ; 6(1 3 <br /> Is permit current? Yes No Permit # - Facility Status Code Doc.Soil/GW Co No <br /> Number of Tanks at facility 3 Age of Tanks(if available) �. Type of Tank Steel FbrgL Sngl Dual <br /> IVI <br /> ]II. TANK HISTORY <br /> was Tank tested? Yes No Failed precision test 7 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. analyzed? Yes Y. Nom BTXE TPH-G I X1TPH-D$( Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage _ overfillbd <br /> unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> I <br /> Sail Samples Received Yes No Depth to Ground Water �� Ref/Year Average Annual Precipitation A- 14 10 25 <br /> On-Site Well(s) Yes No Number 8 Type Irr Dom Pub <br /> S Score S Score S Score 1 <br /> Distance to Welt(s) from Tank ; f • ft jC 10 pts C 9 pts C 5 pts I <br /> ,0 if 0 if . 0 if <br /> ';R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E'E is met :E is met E is met f <br /> Minimum Depth to groundwater from the Soil Sample (feet) >100 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 xxxixxx 26-40\2 <br /> Man-Made conduits which increase vertical migration �j <br /> of leachate (i.e., septic systems, water wells, ponds) None [ noun Present { <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> Sample Result (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 48.pts 40 pts or Less <br /> B T X E B X E <br /> MAXIMUM ALLOWABLE B T-X-E LEVELS (PPM) . 1 50 50 50 .3 J.T <br /> 3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> r o MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH Q DIESEL 10,000 1000 100 <br /> FOOTNOTf� ***If documented soil and/or ground water contamination is present, do not complete the Leaching potential <br /> g1 = analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> 3 \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. ppm (diesel). <br /> \3 Levets for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 <br /> VE. STAFF RECOMMENDATION/CONCLUSION D1 <br /> pp M <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes Wi <br /> p roI� <br /> 2. Recommend Site Closure Yes *If Yes, Refer to ite for Evaluation <br /> LdPP <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR V+MAF"'� <br /> CORCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERREDTOSITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR �,G <br /> i <br /> EH 23 80 (UGTWKSHT)\5/90 <br />