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SAN JOAQUIN COU .'UBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTO ISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE S Z_7 <br /> I <br /> e SWEEPS CODE 2`3 <br /> NAME OF FACILITY I••,.0 r� // <br /> ADDRESS �TYPE <br /> 1V�• �� GTANK IOFUEL �}S J1c� VIS1o_ <br /> 1. GENERAL SITE HISTORY *** <br /> Is permit current? Yes No Permit # - Facility Status Code Doc.Soil/GW Cont Yes No <br /> Number of Tanks at facility <br /> Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> II. TANK HISTORY <br /> tested? Yes No Failed precision test ? Yes No If yes, give date(s) <br /> Was Tank <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 No 81XEITPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic tong-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSP CTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Average Annual Precipitation A= 14 10-25 <br /> Soil Samples Received Yes V o Depth to Ground Water Ref/Year <br /> On-Site Well(s) Yes No Number & Type Irr Dom Pub S Score S Score S Score <br /> ft C 10 pts C 9 pts o 5fpts <br /> Distance to Wells) from Tank O� ft; ft; 0 if 0 it <br /> R condition R condition R condition <br /> E is met E is met E is met <br /> V. Site Feature - Leaching Potential Analysis <br /> Minimum Depth to groundwater from the Soil Sade (feet) ���- (l) 100 51-100 25-50\1 <br /> ) <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> �� <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migrationNoneNone Unknown Present <br /> of leachate (i.e./ septic systems, water wells, ponds) <br /> At least More than <br /> Unique site features: Recharge area, coarse soil, nearby wells. xxxxxx None one one <br /> COLUMN TOTALS»)TOTAL POINTS <br /> J c7 v 7T-. = 37 <br /> Sample Result: (B T X OR E) <br /> RANGE OF TOTAL POINTS 49 pts or more 41 48 p 40 pts or less <br /> $:(S� 1 ND m 8 ]50 <br /> X E B T X E <br /> n: �i��� �=ND MAXIMUM ALLOW BLE B-T-X-E LEVELS (PPM) 1 50 50 .3 .3 1. 1. NA\3 <br /> 10 <br /> Sample Result: <br /> 0-51 GASOLINE 1000 100 MAXIMUM ALLOWABLE TPH LEVELS (PPM) 100 <br /> 4D TPH' DIESEL 10,000 1000 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do fete the leaching po <br /> tential <br /> G7 Contamination List for soil or ground water.) <br /> analysis. (i.e., site is currently on U <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 applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION P <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure Yes No *If Yes, Refer to Site No <br /> for Evaluation 13! U J <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 YES NO <br /> DATE REFERRED <br /> / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />