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SAN JOAWIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL'HEALTH DIVISION _ <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY WEEPS C <br /> L! ODE <br /> G <br /> DDRESS a7 ANK ID p <br /> , <br /> TANK SIZE Spp,. UEL TYPE Ur� <br /> il. GENERAL SITE HISTORY <br /> +* <br /> Is permit current? es o ermit # acility Status Code oc.Soil/GW Cont 1, <br /> es o <br /> umber of Tanks at facility ge of Tanks(if available) [Type of Tank Leel Fbrgl I ISngLI Duall <br /> 111. TANK HISTORY <br /> tis Tank tested7 es I IHOI ailed precision test ? Ifes o If yes, give date(s) <br /> as a repair made to the tank system? IYes No I Ilf yes, what was repaired? <br /> as repair done under inspection? as No ere soil samples analyzed? es I Y to TXE I ITPH-G I PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nkncwn I lother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> soil Samples Received es o epth to Ground Water tqp of/Year t- ;Z6 verage Annual Precipitation = 4 10-25 <br /> )n-Site Wells) as 1 o umber 8 Type Irr om I ub <br /> S Score S Score S Score <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> ' 0 if 0 if 0 if <br /> R condition 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 (feet) !0 >100 1.100 25-50\1 <br /> roctures in subsurface (applies to foothills or mountain areas) L None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxx, 26-40\2 <br /> an-Made conduits which increase vertical migration p <br /> f leachate (i.e., septic systems, water wells, ponds) None i( Unknown resent <br /> lnique site features: Recharge area, coarse soil, nearby wells. At Least Gore than <br /> xxxxx None one one <br /> 7/,C�G / $ 5 <br /> COLUMN TOTALS>>>TOTAL POINTS /-tom <br /> ample Result: (B T QX,OR �E() RANGE OF TOTAL POINTS F pts or more 41 48 pts 40 pts or less <br /> B T X E B T X E <br /> MVS MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> -ample Result: 1 V� ASOLINE 1000 100 10 <br /> OctAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> Ivy T H IESEL 10,000 1000100 <br /> OOTNOTES: ***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 r_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 /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> I2. Recommend Site Closure Ines I L-fO' I � If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE CCHPLETED 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 /> EH 29 80 <br />