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SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL K. •iH DIVISION <br /> !• UST WORKSHEET FOR SIT"c CLOSURE EVALUATION ATE <br /> 2 <br /> NAME OF FACILITY I ECORD ID <br /> bCDRESS O I Alt& ANK ID �/� / O <br /> TANK SIZE I /O o() UEL TYPE p 1177 <br /> !. GENERAL SITE HISTORY <br /> !!s Dermit current? es o ermit R - acility Status Code oc.SoiL/GW Cont es o <br /> Number of Tanks at facility ge of Tank(if available) �iype of Tank teel Fbrgl ngL Dual <br /> f!!. TANK HISTORY <br /> L.'as Tank tested? es o ailed precision test ? es o If yes, give date(s) <br /> las a repair made to the tank system? es I No �f yes, what was repaired.7 <br /> i4as repair done under inspection? �lesl �lol ere soil samples analyzed? es o TXE PH-GP <br /> H-D I b/ED6 <br /> Type of failure/discharge atastrophicl long-term Leakage verfill nown ther: <br /> !V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received �es V o epth to Ground Water of/Year ?20 ;19 verage Annual Precipitation = 4 h0-25 <br /> Pn-Site WeLL(S) 1Yes o f umber & Type IrrI cm ub <br /> S Score S Score S Score <br /> Distance to WeIL(s) from Tank ft; ft; ft C 10 pts C 9 pts C <br /> pts <br /> 0 if 0 if 0 if <br /> R onditicn R condition R ondition <br /> y. Site Feature - Leaching Potential Analysis "c is met E is met E lis met <br /> !^inimum Depth to groundwater from the Soil Sample (feet) Ft- >100 I 1-100 ( O I25-501 <br /> rac:ures in subsurface (applies to foothills or mountain areas) None Unknown bresent <br /> Average Annual Precipitation (inches) KXXXXX <10 9 110-25 xxxxxx 1126-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of Leachate (i.e., septic systems, water wells, ponds) None Unknown bresent <br /> Lnicue site features: Recharge area, coarse soil, or wells. At Least ore than <br /> 'Muncipal=>2000 ft; domestic=>500 ft; irr/agricultural=present) xxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> s mple Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more I 41 - 48 pts 40 pts or Less <br /> E-NDpPI)�� B T X E 8 T X E <br /> X 8c�r�m MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> ample Result: �IES+EL <br /> 1000 100 10 <br /> 71co ppryl ��►� AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> I �y� <br /> —TPH(4) 10,000 1000 100 <br /> FOOTNOTES: <br /> `If documented soil and/or ground water contamination is present, do not complete 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 TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> i. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> � 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> 0 REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> INCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES <br /> L 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED 6ATE CLOSURE LETTER MAILED <br /> t <br /> NAME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />