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SAN JOAQUIN *Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE* DIVISION <br />I, UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br />NAME OF FACILITY � SWEEPS CODE 3 �, r <br />ADDRESS S6 AA 9 TANK ID <br />TANK SIZE FUEL + TYPE <br />.. ..rurn.orre urcrnev J "�� <br />**x <br />s permit current? Yes No Permit # - Facility Status Code Doc.SoiI/GW Cont Yes No <br />lumber of Tanks at facility Age of Tanks(if available) (Type of Tank Steel Fbrgl Sngl Dual <br />III. TANK HISTORY <br />Was Tank tested? <br />Yes <br />No <br />No <br />Failed precision test ? <br />Yes <br />No <br />A= <br />If yes, give dates) <br />!Was a repair made to the tank system? <br />Yes <br />No <br />If yes, what was repaired? <br />Number & Type <br />Was repair done under inspection? Yes <br />Irr <br />No <br />(Were soil samples analyzed? Yes No <br />BTXE <br />TPH-G `TPH-D <br />Pb/EDB <br />Type of failure/discharge <br />catastrophic <br />Long-term leakage <br />overfill <br />unknown <br />other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />(Soil Samples Received Yes <br />RECOMMENDATION FOR <br />No <br />YES NO REFERRED TO SITE MITIGATION FOR EVALUATION <br />Depth to Ground Water <br />Ref/Year <br />Average Annual Precipitation <br />A= <br />14 <br />10-25 <br />On -Site Well(s) <br />Yes <br />No <br />Number & Type <br />Irr <br />Dom <br />Pub <br />S <br />C <br />Score <br />10 pts <br />S <br />C <br />Score <br />9 pts <br />S <br />C <br />Score <br />5 pts <br />Distance to Wells) from Tank <br />ft; ft; ft <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />V. Site Feature - Leaching Potential Analysis <br />I <br />;Minimum Depth to groundwater from the Soil Sample (feet)i�O u <br />>100 <br />151-100 <br />25-50\1 <br />;Fractures in subsurface (applies to foothills or mountain areas) <br />® <br />None <br />, <br />Unknown <br />`Present <br />(Average Annual Precipitation (inches) <br />xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxxxx <br />26-40\2 <br />,Man -Made conduits which increase vertical migration <br />I <br />of leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />Present <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />I <br />xxxxxx <br />None <br />At least <br />one <br />More than <br />one <br />i <br />COLUMN TOTALS»>TOTAL POINTS <br />I <br />+ <br />' r� <br />+ <br />ID <br />Sample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts or more <br />41 - 48 pts <br />40 pts or less <br />D1 - 0,34 X=6. (P <br />D f- 06 9A ► l' 0/7� <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />8 <br />50 <br />50 <br />50 <br />.3 <br />.3 <br />1. <br />1. <br />NA\3 <br />SaJqPt+g: l t <br />1000 <br />100 <br />a "r <br />i? <br />MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br />HGAINE <br />TPH <br />C-.�' <br />10,000 <br />1000 <br />100 <br />FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the feat Ing potentia <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., 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 />41. STAFF RECOMMENDATION/CONCLUSION O�,K ��,�,'u�t✓ (�4-7 <br />* %VI t'"�j 8(' � j v1 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 J <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISORtSENIOR <br />CONCUR WITH STAFF <br />RECOMMENDATION FOR <br />CLOSURE <br />YES NO REFERRED TO SITE MITIGATION FOR EVALUATION <br />YES( NO, <br />DATE REFERRED <br />/1 l / <br />DATE CLOSURE LETTER MAILED <br />NAME OF <br />EVALUATOR <br />- <br />EH 23 80 (UGTWKSHT)\5/90 <br />