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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL IWLTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY - lj l' EEPS CODE <br /> DDRESS 'C��� ` . y� ANK ID # <br /> TANK SIZE �' UEL TYPE <br /> 11. GENERAL SITE,IYSTORY <br /> Is permit current? es o ermit # acility Status Code oc.Soil/GW Cont Ifas 0 <br /> umber of Tanks at facility 9e of Tanks((f available) IType of Tank IS teel Fbrgl ngl Dual <br /> TH <br /> 111. TANK HISTORY <br /> as Tank tested? es o ailed precision test 7 1Yas I Ifol If yes, give date(s) <br /> as a repair made to the tank system? 1Yas No 1 11f yes, what was repaired? <br /> as repair done under inspection? eso ere soil samples analyzed? as to TRE PH-G PH-D b/EDB <br /> ypo of failure/discharge atast rophic long-term leakage verfill nknown cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es 5C o epth to Ground Nater of/Year ;��, verage Annual Precipitation = 4 10-25 <br /> -Site Well(s) 1Yas o umber 8 Type Irr om I ub <br /> S Score S Score 5 Score <br /> tstance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R conditiort R condition R ordition <br /> V. Site Feature . Leaching Potential Analysis E is met E is met E is met <br /> i nimum Depth to groundwater from the Soil Sade (feet) L) >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None ! Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxxx None --��9 one one <br /> COLUMN TOTALS»)TOTAL POINTS + p)� + <br /> ample Result: ,((B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> bTx ( Do PPYY. B T X E B T X E <br /> MAXIMUM ALLOWABLE B.T-X-E LEVELS (PPM) 1 SO 50 50 .3 .3 1. 1. NA\3 <br /> Sample ResulASOLiNE 1000 100 10 <br /> N D Iryrypp AXIMUM ALLOWABLE TPH LEVELS (PPM) IG — <br /> I UH IESEL 10,000 1000 100 <br /> DOTNOTES: **-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 r_5 ft., do not use table. <br /> \2 1f precipitation is > 40 inches, score 0 points. <br /> \3 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 TPN Concentrations > Allowable Levels Yes <br /> I2. Recom erd Site Closure Fes I .--Fo I 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 1YES I lN01 lREFERRED TO SITE MITIGATION FOR EVALUATION ES 1 40 <br /> .ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />