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SAN JOAQUIN COUA..0UEILIC HEALTH SERVICES/ENVIRONMENTAL HEALTH I�ISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE L' <br /> NAME OF FACILITY y 1`- -5-9661 <br /> ,1/ 1 1? SWEEPS CODE 3 <br /> (ADDRESS7�7� / C S TANK ID # - <br /> TANK S I ZE A) TYPE �'�� J ted" ( / h eY)' Cl 4t. <br /> I. GENERAL SITE HISTORY <br /> ter+ <br /> ! lls permit current? Yes No Permit it - (Facility Status Code Doc.Soil/GLI Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) ��. Type of Tank SteeL Fbr9L 5n9L Dual <br /> Ii. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? 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 snit sampLes anatyzed?. Yes No 3TXEj . TPH-G TPH_D Pb/ED8 <br /> Type of failure/discharge catastrophic Long-term Leakage 7.verfiLL unknown other: <br /> V. 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/Tear 81D Average Annual Precipitation A= 14 10-25 <br /> C Site ells) Yes No Neer & Type Irr Dam Pub <br /> S Scare S Score S Score <br /> Distance to WeLL(S) from Tank l ft; ft; ft C 10 pts C if C 5 pts <br /> O if 0 if 0 if <br /> f P I e 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)1 .0 I >100 51-100 25-50\1 . <br /> Fractures in subsurface (applies to foothills or mountain areas) I Nene 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, pards) f(� None Unknown I 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 + + + 1 <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more I 41 - 48 pts 40 pts or Less <br /> >� B T X E e T x E <br /> ' MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50I 50 50 .3 .3 1.I 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 ` <br /> L&W q <br /> at" <br /> XIMUM ALLOWABLE TPH LEVELS (PPM) 100TPN! DIESEL 10,000 1000 <br /> r <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not compLete the Leaching <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 tabte. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasotine) or 100 ppm (dieset). <br /> VI. STAFF RECOMMENDATION/CONCLUSION Pr i h r�— <5 CL <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Ciasu <br /> re Yes No *If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR tj1i <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 /> $H 23 80 (UGTWKSHT)\5/90 <br />