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SAN JOAQUIN eWNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HL"tCTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY EEPS COOE <br /> DRESS ANK 10 # <br /> l <br /> TANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # - acility Status Code oc.Soi I/Gw Cont es7 El <br /> o <br /> umber of Tanks at facility ge of Tanks(if available) IT <br /> ype of Tank tee? FbrgL I l3rgL I Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspecti on7 es No ere soil samples a"Lyzed? es o TXE I PH-G I PH-D I b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill knownI lo then. <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water of/Year verage AnnuaL Precipitation = 4 0-25 <br /> n-Site WeIL(S) es o umber & Type Irr an ub <br /> S Score S core S Score <br /> istance to WeLL(s) from Tank ft; ft; ft C 10 pts C pts C 5 pts <br /> 0 if 0 1f 0 if <br /> R ondition R ondition R ondition <br /> 1. Site Feature - Leaching Potential AnaLysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet)-;:, >100 1-100 25-50L <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxxxxx 26-401 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby weLLs. At least ore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS * ' <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS P pts or more 41 - 48 pts 40 pts or Less <br /> rlr. B I T % E B T % E <br /> MAXIML14 ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA1 <br /> ample Result: SOLINE 1000 100 10 <br /> �T ! AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 1 10,000 1000 100 <br /> FOOTNOTES: `•`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 /> L 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 /> VI. STAFF RECOMMENDATION/CONCLUSION b' — p I� -./- �j _ ,� <br /> 1. Are BTX & E or TPM Concentrations > ALLowable Levels Yes o —//��J / �'yL(�{Q v///�,QYy1 <br /> 2. Recommend Site Closureo - If Yes, Refer to Site Mitigation for Evaluation 0a S <br /> es ��>'l <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR — - <br /> r <br /> w{ <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED F <br /> ATE CLOSURE LETTER MAILED <br /> AME OF: <br /> F <br /> VALUATORS(`^rte _ / <br /> EH 23 80 (UGTWKSHT)\5/90 <br />