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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL iZ LTH DIVISION <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> nME OF FACILITY — PYA I WEEPS CODE i <br /> ,DDRESS L, v ----- <br /> - i_U C �! _ (- �� — " �'C T ski 662 <br /> ID # �- 6G C� <br /> LANK SIZE (,'Cy)o UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> xt <br /> Is permit current? es o ermit # - acility Status Code oc.Soil/GW Cont 1Yes o <br /> umber of Tanks at facility U�l-Q ge of Tanks(if available) ype of Tank Leel Fbrgl I knal Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o IF <br /> ailed precision test ? es X o If yes, give date(s) <br /> as a repair made to the tank system? es No 11f yes, what was repaired? <br /> as repair done under inspection? es 40 ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage I verf ill nknown I la <br /> Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received eso epth to Ground Water of/Year ;�� verage Annual Precipitation = 4 0-25 <br /> 2)n-Site Well(s) es o umber & Type Irr om ✓ ub <br /> S Score S Score s Score <br /> istance to WeLL(S) from Tank JL-LL-ft; ft; ft C 10 pts C 9 pts C 5 pis <br /> 0 if O if O if <br /> R onditi of R condition 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) <br /> ample (feet ' — >100 — 1-100 25-50\1 <br /> Fractures in subsurface (applies to foothi Lls,tinto aim ea "�� More Unknown resent <br /> verage Annual Precipitation (inches) xxxxx 00 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical/migration / <br /> f leachate (i.e., septic systems, water wells, pods) --- None - Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxx None one S one <br /> COLUMN TOTALS»>TOTAL POINTS + + J`I <br /> 3ampLe Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> -i G • B T K E B T X. E <br /> X 3�� MAXIMUM ALLOWABLE B-T-%-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> IESEL 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 /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are 8T% & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure 1Y <br /> 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 />