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SAN JOAQUIN C=JNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HL,-.,H DIVISION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE �� 9 <br /> AME OF FACILITY f� G WEEPS CODE <br /> - <br /> G �� C ANK 1D # <br /> TANK SIZE IFUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # - acility Status Code oc.Soi L/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) IType of Tank IS <br /> tee[ Fbrgl ngl I Dual <br /> 111. TANK HISTORY <br /> as Tank tested7 es IF <br /> ailed precision test 7 as o If yes, give date(s) <br /> as a repair made to the tank system? as No 1 11f yes, what was repaired? <br /> as repair done under inspecti on7 Fe <br /> s ere soil samples analyzed? as o TXE PH-G PH-D b/EDB <br /> o <br /> Type of failure/discharge atastrophic long-term Leakage verfill I knkn,own cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSTS) <br /> Soil Samples Received as o epth to Ground Water of/Year O j ; .V verage Annual Precipitation 4 0-25 <br /> n-Site WeLL(S) as o umber & Type Irr om ub <br /> S Score S Score S Score <br /> istance to Wells) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 if 0 if 0 if <br /> R onditi on R condition R ondi ti on <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feeUj >100 1-100 25-50L <br /> Fractures in subsurface (applies to foothills or mountain areas) More Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 KxxXmx 26-4012 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) VW`� None Unknown resent <br /> pique site features: Recharge area, coarse soil, 'Marby well] At least 4ore than <br /> xxxx None One one <br /> COLUMN TOTALS»>TOTAL POINTS + + <br /> Sample <br /> /Result: IS T X OR E) RANGE OF TOTAL POINTS P pts or more 41 - 48 pts 40 pts or Less <br /> ✓n/ ` NA)® to r k) MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) B1 50 50 50 .3 .3 1. 1. NAL <br /> Sample Result.�7p ASOLINE 1000 100 10 <br /> Nv pU <br /> pep <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) IE SEL 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 rot use table. <br /> \2 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 /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es 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 />