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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEArA DIVISION �. '� <br />UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br />- EEPS CODE��- <br />•, Y -C ei.Lr.C� AnE OF FACILITY eVg" `vDI ANK ID 8 -01 <br />DDRESS ,ZlA <br />TANK SIZE 5 5C, gral UEL TYPE 0_5U <br />ENERAi SITE HISTORY <br />:s permit <br />current? <br />es <br />o <br />o <br />ailed precision test ? <br />ermit If <br />of/Year <br />acility Status Code <br />J l <br />oc.Soil/GW <br />Con <br />es <br />-Site Well(s) <br />o <br />eso <br />umber of <br />Tanks at <br />facility <br />to <br />Irr <br />he of Tanks(it available) <br />VII <br />ype of lank <br />teel <br />PH•D <br />brgl <br />b/EDS <br />ngl Oual <br />Type of failure/discharge <br />III. TANK HISTORY <br />as Tank tested <br />? <br />es <br />I <br />o <br />0 <br />ailed precision test ? <br />es <br />of/Year <br />o <br />if <br />yes, give date(s) <br />4 <br />as a repair made to the tank system? IYes No f yes, what was repaired? <br />-Site Well(s) <br />ns repair done under inspecti on7 <br />eso <br />ere soil samples analyzed? <br />es <br />umber 8 Type <br />to <br />Irr <br />TXE <br />om <br />PH -G <br />ub <br />PH•D <br />Score <br />b/EDS <br />Score <br />Type of failure/discharge <br />Score <br />atastroph is <br />long-term leakage <br />istance to Wells) from Tank <br />verfill <br />C <br />0 <br />R <br />nknown <br />Wa <br />ther: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />soil Samples Received <br />as <br />I <br />oepth <br />0 <br />toCrowd Water <br />5 <br />of/Year <br />, ; K2 <br />verage Annual Precipitation <br />= <br />4 <br />10-25 <br />-Site Well(s) <br />as I <br />o <br />umber 8 Type <br />I <br />Irr <br />I <br />om <br />ub <br />S <br />Score <br />S <br />Score <br />S <br />Score <br />istance to Wells) from Tank <br />ft; ft; ft <br />C <br />0 <br />R <br />10 pts <br />if <br />oditi on <br />C <br />0 <br />R <br />9 pts <br />if <br />oditi on <br />C <br />0 <br />R <br />5 pts <br />if <br />ondition <br />V. Site Feature - Leaching Potential Analysis <br />E <br />is met <br />E <br />is met <br />E <br />is met <br />inimxxm Depth to groundwater from the Soil Sample (feet)J5— - 4` <br />>100 <br />1.100 <br />O <br />25-50\1 <br />ractures in subsurface (applies to foothills or mountain areas) <br />None <br />ClUnknown <br />resent <br />r <br />verage Annual Precipitation (inches) <br />KXXXXX <br /><10 <br />9 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />an -Made conduits which increase vertical migration <br />f leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />Dresent <br />Inique site features: Recharge area, coarse soil, nearby welts. <br />At least <br />4ore than <br />xxxxx <br />None <br />one <br />one <br />COLUMN TOTALS>>>TOTAL POINTS <br />* <br />3 <br />+ <br />� <br />ample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />9 pts or more <br />41 • 48 pts <br />40 pts or less <br />&NND-.z K- i.LL_ <br />f-ND•.2 p�h1 <br />MAXIMUM ALLOWABLE B-T•X•E LEVELS (PPM) <br />1 <br />1 <br />L % <br />50 50 <br />E <br />50 <br />B <br />.3 <br />T <br />.3 <br />X <br />1. <br />E <br />1. <br />NA\3 <br />'a l Result: <br />ASOLINE <br />1000 <br />100 <br />10 <br />2.3 TPH PPM <br />AXIMUM ALLOWABLE TPH LEVELS (PPM) <br />IESEL <br />10,000 <br />1000 <br />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 />\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 b+Ak LGA4 <br />)3.q <br />1, Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o ,yy_ Nck :` <br />2. Reconmend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO BE COMPLETED D A SUPERVISOR/SENIOR <br />.ONCUR WITH STAFF RECOMMENDATION FOR <br />CLOSURE <br />"ES <br />0 <br />EFERRED TO SITE MITIGATION FOR EVALUATION <br />ES <br />0 <br />ATE REFERRED <br />_� -1-2-1 / <br />,� <br />ATE CLOSURE LETTER MAILED <br />AME OF <br />�7Le'- <br />-VALUATOR <br />7 lam✓ =\-d <br />EH 23 80 (UGTWKSHT)\5/90 <br />Ex 29 80 <br />