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SAN JOAOUTA COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL .TH DIVISION <br /> 1' UGST WORKSHEET FOR SITE CLOSURE EVALUATIOI. ATE 3- — <br /> AME OF FACILITY D-� C J'1 ,j WEEPS CODE <br /> DRESS ANK ID # - <br /> ANK SIZE L TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current] es o ermit # acil ity Status Codea.Soi l/GW Cont as o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank teel brgl ngI Dual <br /> 111. TANK HISTORY <br /> as Tank test ? es o IF ailed precision test 7 e <br /> eds o If yes, give date(s) <br /> Jas a repair made to the tank system? IYes No f yes, what was repaired? <br /> Jas repair done under inspection? es 1 40 ere soil samples analyzed? 1, <br /> es o TXE PM-G PH-D b/EDB <br /> Type of failure/discharge arastrophic long-term leakage verfill noun I iather- <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water Loo of/Year && verage Annual Precipitation III= 11 <br /> 4 0-25 <br /> -Site Wells) es o umber 8 Type Irr om ub <br /> S core S Score S core <br /> istance to WeIL(s) from Tank ft; ft; ft C 0 pts C 9 pts C pts <br /> 0 1f 0 if 0 f <br /> R ondi tion R condition R ondi tion <br /> W. Site Feature - Leaching Potential Analysis E is met E is met E 's met <br /> inimum Depth to groundwater from the Soil Sample (feet) (/d-r(J >100 1.100 `'�3 25-50L <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> %verage Annual Precipitation (inches) Xmx <10 9 10-25 xmx 26-40L <br /> an-Made conduits which increase vertical migration Q <br /> f leachate (i.e., septic systems, water wells, ponds) None ( Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. Q At least 4ore than <br /> xxxx None77 ( one one <br /> COLUMN TOTALS»>TOTAL POINTS ' U . 6-, + S �- <br /> Sample Result: (B T X ORo 1E�) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> ttdwaof S � g 0 f B T % E 8 T X. E <br /> ,j- 0IdSFPb E� ij0a 'IdfP MAXIML14 ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NI <br /> ample Result: ASOLI NE 1000 100 10 <br /> oft I U /n IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTES: =••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 /> L If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> L If prec1pitati on is > 40 inches, score 0 points. <br /> •L3 Levels for BTXBE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > AIIowable Levels Yes o <br /> I2. Recommend Site Closure lYes I L- LL�If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 Ef ERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED / / <br /> AME OF <br /> EH 23 80 (UGTWKSHT)\5/90 <br />