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Is permit current? <br />SAN JOAQUIN <br />C( ' PUBLIC HEALTH SERVICESANVIRONMENTAL <br />HE ' IVISION <br />i. <br />- <br />UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br />DATE <br />d <br />NAME OF FACILITY <br />/ r /Yj' <br />No <br />' No <br />Number of Tanks at facility <br />SWEEPS CODE <br />Age of Tanks(if available) <br />Was repair done under inspection? <br />ADDRESS <br />`� / <br />~ <br />Fbrgl <br />Yes No BTXE <br />TANK ID # <br />Dual <br />TPN -D <br />TANK SIZE <br />FUEL TYPE <br />Type of failure/discharge <br />catastrophic <br />II. GENERAL SITE HISTORY <br />long-term leakage <br />overfill <br />Is permit current? <br />Yes <br />A AINo <br />No <br />Permit # <br />- <br />Facility Status Code <br />No <br />Doc.Soil/GW Cont <br />Yes <br />/ r /Yj' <br />No <br />' No <br />Number of Tanks at facility <br />if yes, what was repaired? <br />Age of Tanks(if available) <br />Was repair done under inspection? <br />Type of Tank <br />Steel <br />Irr <br />Fbrgl <br />Yes No BTXE <br />Sngl <br />Dual <br />TPN -D <br />III. TANK HISTORY <br />Was Tank tested? <br />Yes <br />A AINo <br />No <br />Failed precision test ? <br />Yes <br />Ref/Year <br />No <br />If <br />yes, give date(s) <br />/ r /Yj' <br />Was a repair made to the tank system? Yes <br />' No <br />Yes <br />if yes, what was repaired? <br />No <br />Was repair done under inspection? <br />YesNo <br />Irr <br />Were soil samples analyzed? <br />Yes No BTXE <br />TPN -G <br />TPN -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 />No <br />Depth to Ground Water <br />50, <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 />Dan <br />Pub <br />S <br />Score <br />S <br />Score <br />S <br />Score <br />Distance to WeII(s) from Tank <br />ft; ft; ft C <br />10 pts <br />C <br />9 pts <br />C <br />5 pts <br />0 <br />if <br />0 <br />if <br />0 <br />if <br />R <br />condition <br />R <br />condition <br />R <br />condition <br />V. Site Feature - Leaching Potential Analysis E <br />is met <br />E <br />is met <br />E <br />is met <br />Minimum Depth to groundwater from the Soil Sample (feet) 50 —/-3 -3 , <br />>100 <br />51-100 <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) 1 <br />None <br />Unknown <br />Present <br />Average Annual Precipitation (inches) xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />of leachate'(i.e., septic systems, water wells, ponds) I U <br />None <br />Unknown <br />Present <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />At least <br />More than <br />xxxxxx <br />None <br />one <br />one <br />I -KI 1= o. G0k t3 46? <br />j0 , �� COLUMN TOTALS>>>TOTAL POINTS 2D I <br />+ <br />/ <br />+ <br />_ <br />Simle R suit: (B T X OR E) 1K/ 7 �! RANGE OF TOTAL POINTS 49 pts or more <br />i� (lv� <br />n t B T X E <br />- 48 is <br />40 pts or less <br />B <br />X/U <br />I MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 5 <br />.3 J.T <br />3 <br />1. <br />1. <br />NA\3 <br />Sample Result:GASOLINE <br />TP )4 e N b TPN <br />MAXIMUM ALLOWABLE TPN LEVELS (PPM) <br />DIESEL <br />1000 <br />100 <br />10 <br />10,000 <br />1000 <br />100 <br />FOOTNOTES: ***If documented soil and/or ground water contamination is present, do ete the leaching potential <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 TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOMMENDATION/CONCLUSION / <br />c e� <br />1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No 1 a 7 <br />2. Recommend Site Closure Yes No *If Yes, Refer to Site Mitigation for Evaluation T13 E ti T <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR !rC <br />'CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES <br />DATE REFERRED Z / / DATE C OSURE LETTER MAILED <br />NAME OF <br />EH 23 80 (UGTWKSHT)\5/90 <br />