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LALTIQ1SICH <br /> SAN JOACUIN CCUi UBLIC HEALTH SERVICES/ENVIRCNMEYTAL <br /> 1. UGSi XRKSHEET FOR SITE CLOSURE EVALUATION} ATE Eli <br /> 2 A7 <br /> AHE OF FAC1LIiY - EEPS CODE <br /> �!�'rrrr .'� �:'.'r. fc a / i > Cr�r,t'Irr�i'v <br /> RORE55 <br /> `7S _4 TANK ID X <br /> TANK SIZE UEL TYPE <br /> 11. GE?IERAL SITE`HISTORY <br /> Is permit current? es a ermit 0 - aei€ity Status Code d oc.Soit/GLI Cont as o <br /> usher of Tanks at facility kge of Tanks(if avaitabte) ype,jof Tank telt I Fbrgl mgt Oat <br /> III. TANK HISTORY <br /> as Tank tested7 eso ailed precision test ? es ( o if yes, give date(s) <br /> I <br /> as a repair made to the tank system? as No D <br /> f yes, what was repaired? iI <br /> 'ns repair done under inspectioni as 40 ere sail samptes analyzed? as I o TXE PH-G PH-D b/EDB <br /> 11�ype of failure/discharge atastraphic long-term leakage verfill nknan Cher: <br /> a <br /> 1V• REMOVAL HISTORY (ATTACH INSPECTION REPORT FCR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .i <br /> oit Samples Received as - epth to Ground Water 91,3' ef/Year 5- ; = verage Annuat Precipitation <br /> -Site Vett(s) es o ufiber & Type 11 r cm - b <br /> � S oorel S care 5 cora <br /> istance to Wells) from Tank __7Lft; ft; ft C 0 pts C 9 pts C pts <br /> 0 if I� 0 if e f <br /> R ondition R condition R ordition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> -i <br /> inimun Depth to groundwater from the Soit Sample (feet) >100IL 1-100 25-50\1 <br /> rac:ures in subsurface (applies to foothitts or mountain areas) None) Unknown 3resent <br /> verage Annual. Precipitation (inches) KXXXXX <10 I 9 10-25 xxxxxx 26-40\2 <br /> an-rade conduits which increase vertical migration <br /> t Leachate (i.e., septic systems, water wells, ponds) None Unknown PIresent <br /> nitue site features: Recharge area, coarse soil, nearby welts. At least lore than <br /> xxxx Nene one one <br /> COLUMN TOTALS>>>TOTAL POINTS + 3 6 + S 4 I <br /> ample Result: (a T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts y__40--pts..or less <br /> B T X E 8 T % E '.. <br /> X 1;3 0 �'•3'7`7 <br /> MAXIMLH ALLCWA8LE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> ample Result: ASCLINE 1000 i 100 i 10 I <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 3/GlO0 TPH-6 1ESEL 10,000 1040 100 <br /> COTxOTES: *" If documented soil and/or ground water contamination Is present;Jdo not caaptete the teaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or grouid water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <4 f.`t., do not use table. <br /> \2 if precipitation is > 40 inches, score 0 points. I <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> i <br />'VI. STAFF REC."tWEMOAT 10141CCNCLUSION i <br /> 1. Are 3TX E or TPH Concentrations > Altowabte Levels Yes o <br /> 2. Recommend Site Closure as a If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATICN - TO BE CCHPLETED BY A SUPERVISOR/SENIOR <br /> CNC`UR WITH'STAFF RECCNMENDATION FOR CLOSURE E5 0 EFERRED TO SITE HITIGATIGN FOR EVALUATION VES 0 <br /> ATE REFERRED1 !7 / ! ATE CLOSURE LETTER MAILED / •� / <br /> 1AME OF <br /> :VALUATOR <br /> EN 23 80 (UGTuxSHT)\5/90 <br />