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SAN JOAQUIN CONAmOPUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL:. ISION1. ATE <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> AME OF FACILITY G WEEPS CODE <br /> ✓ r <br /> qNK ID # <br /> DDRESS —� ( �g �p ` <br /> TANK SIZE I 4poL,) L TYPE <br /> 11. GENERAL SITE HISTO Y +• <br /> Is permit current? es o ermit # acility Status Code oc.Soil/GW Cont oso <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank Teel Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested? as o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? Yes No f yes, What was repaired7 <br /> ns repair done under inspection? es o ere soil samples analyzed? es 10 T%E PH-G 1TPH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verf ill nknown ther: <br /> IV, REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Foil Samples Received es o epth to Ground Water q, of/Year J IS6 verage Annual Preci pita[ion = 4 10-25 <br /> -Site Wetl(s) IT <br /> as o umber 8 Type Irr om I ub <br /> S core S Score 5 3core <br /> istance to Wells) from Tank ft; ft; ft - C 0 pts C 9 pts C 5 pts <br /> '0 1f 0 if 0 if <br /> R ondition R ondition R zondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met Es met <br /> inimum Depth to groundwater from the Soil Sample (feet) >1001-100 5� 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) O NonelAt <br /> Unknown resent <br /> verage Annual Precipitation (inches) xxxxx <10 10-25 xxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration c� <br /> of leachate (i.e., septic systems, water wells, ponds) NoneUnknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. Least lore than <br /> xxxxx None one / one <br /> COLUMN TOTALS>>>TOTAL POINTS ,x 10 <br /> ample Result: (0 T X OR E) RANGE OF TOTAL POINTS F9 pts or more 41 - 48 pts 40 pts or less <br /> B E <br /> MAXIMUM ALLOWABLE B•T-%-E LEVELS (PPM) 1 5075 50 .3 .3 1. 1. NA\3 <br /> Sample Result: �{�,/�. ASOLINE 1000 100 10 <br /> fY\ ����Cs� A%IMUM ALLOWABLE TPH LEVELS (PPM) 1. <br /> a�l 'TBH IESEI 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 /> \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 <br /> t- Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es F 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 /> Ex 29 80 <br />