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d � �r l o r( y 1 tk_(Tn,5eS . <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION / <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> NAME OF FACILITY ISWEEPS CODE <br /> DDRESS ANK ID p <br /> TANK SIZE IFUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> •R <br /> Is permit current? eso ermit q acitity Status Code cc.Soil/GW Cont es 10 <br /> umber of Tanks at facility ge of Tanks(if available) IType of Tank IS Teel Fbrgl I IS <br /> ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? as o IF <br /> ailed precision test ? as INO If yes, give date(s) <br /> as a repair made to the tank system? 1Yas No 1 11f yes, what was repaired7 <br /> ns repair done under inspection? as No I ere soil samples analyzed? IT <br /> es I 10 I TXE I PH•G I PH-D b/EDO <br /> Type of failure/discharge atastrophic long-term leakage I 1Dverfill nkncwn 1 10 <br /> ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Foil Samples Received as 0 epth to Ground Water cf/Year verage Annual Precipitation k= 4 10-25 <br /> -Site Wells) es o umber & Type Irr an ub <br /> S Score S Score S Score <br /> istance to Wetl(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R onditi on R conditi on R ordition <br /> v. Site Feature . Leaching Potential Analysis E is met E is met E is met <br /> ini mum Depth to groundwater from the Soil Sample (feet) >100 1.100 25.50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) 1 None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration / <br /> f leachate (i.e., septic systems, water wells, ponds) 'l D None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least [� ore than <br /> nnxxxxx None one �J one <br /> COLUMN TOTALS>>>TOTAL POINTS _6 + L ♦ S j <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B T % E B T % E <br /> MAXIMUM ALLOWABLE B-T-%-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> -ample Result: ASOLIRE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 1 10,000 1000 100 <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 <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for 8T%&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION r f <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes IN. L.{/ <br /> I2. Recommend Site Closure as I �0 I If Yes, Refer to Site Mitigation for EvaLuati on <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR 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 />