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i <br /> SAN JOAOUIN `�EI)NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEJH DIVISION <br /> I UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> ATE <br /> AMIE OF FACILITY <br /> WEEPS CODE a L <br /> DpRESS �} /1� <br /> 3`-t 31 S ' l�W Uji ANK 10 p 3 <br /> ANK SIZE a(� UEL TYPE <br /> It. GENERAL SITE HISTORY i k <br /> I permit current? es o ermit tf ** <br /> acility Status Code oc.Soil/GW Cont es x o <br /> umber of Tanks at facility �, ge of Tanks(if available) <br /> 3 �� ype of Tank feel X Fbrgl ngl Dual <br /> j III. TANK HISTORY <br /> I�. f <br /> as Tank tested? es o ailed precision test ? es o If yes, give dates) <br /> as a repair made to the tank System? es No f yes, what was repaired? <br /> i <br /> ns repair done under inspection? es o ere soit samples analyzed? 'es x Jo TXE PH-G PH-D b/EDO <br /> YPe of faiture/discharge atastrophic long-term leakage verfill nknown Cher: <br /> ]V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water 3� of/Year p�j <br /> ilk�o; verage Annual Precipitation = 4 110-25 <br /> n site Welts) es o umber 8 Type lrr Pon I ub <br /> istance to Welt(s) from Tank _f t; _f t; . ft C 'Oorts C Gare S core <br /> P pts C i pts <br /> 0 if 0 if 0 •f <br /> R -ondition R ondition R ondition } <br /> Site Feature Leaching Potential AnalysisE is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) j>100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) Q iNone Unknown Dresent <br /> verage Annual Precipitation (inches) xxxxx <10 4 10-25 Kxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration F� ` <br /> Df leachate (i.e., septic systems, water wells, ponds) Mone Unknown >resent !I <br /> tnique site features: Recharge area, coarse soil, nearby Hells. At least 4oFe than <br /> xxxxx None one one <br /> i • <br /> COLUMN TOTALS—TOTAL POINTSl� �- 0 <br /> y <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTSf9 pts or more . 41 48 pts �_40 pts or less <br /> J. <br /> B i x E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 SO .3 3 1. 1. NA\3 <br /> 'ample Result: ASOLINE 1000 100 10. <br /> AXIMUM ALLOWABLE TPH LEVELS.(PPM) <br /> TPH IESEL. 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the Leaching potential r <br /> analysis. (i.e., site is currently on UGT -Contaminat'fon 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, scare 0 points. <br /> 13 Levels for BTX8E arenot applicable at a TPH concentration of 10 ppm (gasoline) o 00 ppm (diesel). <br /> F <br /> V1. STAFF RECOMMENDATION/CONCLUSION I <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> I <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitfgation far Evaluation ' <br /> V11. REVIEW EVALUATION - TO BE COf4PLETED BY A SUPERVISOR/SENIOR i <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES JO <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED , <br /> AME OF <br /> :VALUATOR li <br /> Eli 23 80 (UGTWKSHT)\5/90 <br /> i a <br /> EH 29 80 I . _ <br />