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SAN JOAQUIN L )NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA-.4 DIVISION (/ <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY LQ_� 6�y�_C- ,I/ EEPS CODE <br /> ODRESS cJ I F r� ANK ID # <br /> TANK S12EUEL TYPE <br /> It. GENERAL SITE HISTORY <br /> Is permit current? es I IN01 acility Status Code oc.Soil/GW Cont es Io <br /> +umber of Tanks et facility) �1ge of Tanks(if available) ype of Tank teal Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? as IN01 ailed precision test ? es I IN01 If yes, give date(s) / / <br /> Was a repair made to the tank system? as No f yes, what was repaired? <br /> ns repair dunder inspection? as <br /> one o ere soil samples analyzed? es 7o I TXE PH-G I PH-D b/EDD <br /> ype of failure/discharge atastrophic long-term leakage I verfill nknown1 10 cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es I IN01 epth to Ground Water s of/Year ��'�'� verage Annual Precipitation N= 11 <br /> 4 10-25 <br /> -Site Well(s) es o umber 8 Type Irr om ub <br /> S Score S core S core <br /> is[ance to Well(s> from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 if 0 1f 0 if <br /> R ond!tion R ondition R ondition <br /> v. Site Feature • Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >1001-100 25-50\1 Wer <br /> ractures in subsurface (applies to foothills or mountain areas) /Q None Unknown resent <br /> verage Annual Precipitation (inches) xxxxx <10 9 10-25 xxxxxx 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 /> lnique site features: Recharge area, coarse soil, nearby wells. (; At least 4orc than <br /> xxxxx None I one one <br /> COLUMN TOTALS»>TOTAL POINTS I O + <br /> ampple Result: (B TF <br /> .TQ X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> N� X l m B I T % E 8 T % E <br /> MA% <br /> I Ml1M ALLOWABLE B-T•X•E LEVELS (PPM) 1 50 050 50 .3 .3 1. 1. NA\3 <br /> Sample Result: QQ ASOLINE 1000 100 10 <br /> IIIM AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 1 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 /> \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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION r-w(s{��/�- <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o U_T Co 1� F� <br /> I2. Recommend Site Closure hes I �o I �lf Yes, Refer to Site Mitigation for Evaluat�_( A /�/gd'1 <br /> VII. REVIEW EVALUATION • TO BE COMPLETED BY A SUPERVISOR/SENIOR /" O -v( <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE 'ES '0 EFERRED TO SITE MITIGATION F6 EVALUATION ES JO <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />