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M <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA1-r9 DIVISION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 11-lLhl <br /> AME OF FACILITY WEEPS CODE <br /> aw d ✓ <br /> *DRESS 6 �- �TYPJE ANK ID N <br /> ANK SI2E a_ UE <br /> 11. GENERAL SITE HISTORYJ <br /> Is permit current? es o ermit p lFaciLity Status Code oc.soil/GW Cont IYes Fo <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank Leel Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> 'as Tank tested? Ires o ailed precision test ? as o If yes, give date(s) <br /> as a repair made to the tank system? as No f yes, what was repaired? <br /> ns repair done under inspection? as o ere soil samples analyzed? es to TXE PH•G PH-D b/EDD <br /> ype of failure/discharge atastrophic lon -tverfill <br /> germ leakage nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received as o I epth to Ground Water d of/Year I y ; �yc, verage Annual Precipitation k= 11 <br /> 4 10.25 <br /> )n-Site Well(s) as I o I umber 8 Type I Irr I ub <br /> S Score 5 Score S core <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 'f <br /> R ondition R condition R ondi ti on <br /> F. Site Feature - Leaching Potential Analysis E is met E is met E 's met <br /> Depth to groundwater from the Soil Sample (feet) )100 1-100 25.50\1 <br /> es in subsurface (applies to foothills or mountain areas) /! None ig Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26-40\2 <br /> nn-Made conduits which increase vertical migration <br /> 1 leachate (i.e,, septic systems, water wells, ponds) None ,.9, Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At Least lore than <br /> exxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + � + C u <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> m <br /> 8 T X E B T X E <br /> MAXIMUM ALLOWABLE B•T-X•E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> -ample Resu t: ASOLINE 1000 100 10 <br /> Lvl0 � AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> P�PH IESEL 10,000 1000 100 <br /> OD7NOTES: --*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 TPM concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes I IHOI <br /> L2. Recommend Site Closure hes I X�o I �'If Yes, Refer to Site Mitigation for Evaluation <br /> V11. 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 1,?- 7 1 - <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />