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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL He H DIVISION <br /> I, UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY �- laA — WEEPS CODE <br /> DRESS 3`L CO ANK ID # <br /> TANK SIZE I()C Lr UEL TYPE �.. <br /> 11. GENERAL SITE HISTORY <br /> R1 <br /> Is permit current? es o ermit # - acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility Be of Tanks(if avef fable) ype of Tank Leel Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested? es 1 140 1 IF&tied precision test ? as o If yes, give date(s) <br /> Jas a repair made to the tank system? Yes No 11f yes, what was repaired? <br /> Jas repair time under Inspection? es o ere soil samples analyzed? Fee I TXE PH-G I PH-D b/EDB <br /> Type of failure/discharge atastrophic long-Lena leakage I loverfil.l. nknown 1 10cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Solt Salates Received as o epth to Ground Water cId of/Year rye,j ;L?(. verege Annual Precipitation = G 0-25 <br /> -Site Wells) es 1 11 <br /> o 1 Ilumber A Type Irr I am I ub <br /> 5 core S Score S Score <br /> Distance to Walls) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if O if 0 if <br /> R conditim R condition R bordition <br /> 1. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimua Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) p None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <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 5 resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxxx None me one <br /> COLUMN TOTALS»>TOTAL POINTS t / �' * -� — —� <br /> empte Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> '8 b;1- Ppb 33PPb BTX E B T X E <br /> ( 1-7 �O b8 .31 f�b MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> ample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> I 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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX d E or TPN Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure as o 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 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />