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SAN JOAQUIN COUNOBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTIfISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE 31g 5 9 <br /> NAME OF FACILITY SWEEPS CODEIlk <br /> ADDRESS / TANK ID # - 0 <br /> TANK SIZE jj!�5 10 FUEL TYPE C <br /> It. GENERAL SITE HISTORY <br /> *** <br /> Is permit current? Yes No Permit # - Facility Status Code Doc. oil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steel Fbrgl Sngl Dual <br /> II. TANK HISTORY a <br /> 'Was Tank tested? YesNo Failed precision test ? Yes No if yes, give date(s) <br /> lWas a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? YesNo Were soil samples analyzed? Yes No BTXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water Ref/Year Average Annual Precipitation A= 14 10-25 <br /> On-Site Welt(s) Yes No Number & Type Irr Dan Pub <br /> S Score S Score S Score <br /> Distance to Welts) 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 - Leaching Potential Analysis E is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 25-50\1 <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 /> COLUMN TOTALS>>>TOTAL POINTS + + I- <br /> Sample <br /> Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> BT X E 8 T 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 j 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 1 10,000 1 1000 1 100 <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 soft-or ground water.) <br /> \ 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 2ECOMMENDATION/CONCLUSION ',n �y�Q�2 <br /> 1. Are BTX & E or TPN Concentrations > towable Levels *Yes No W ( hA' <br /> 2. Recommend Site Closure Yes NoIV 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 YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />