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SAN JOAGUIN`COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL M�LTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 1 ,a <br /> AME OF FACILITY WEEPS CODE <br /> DDRESS [TANK to-# <br /> TANK S12E oZ �/ UEL TYPE <br /> Ii. GENERAL SITE HISTORY <br /> Is permit current? es o ermit N I acuity Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) IType of Tank teel Fbrgl rgl Dual <br /> 111. TANK HISTORY <br /> as Tank tested7 es 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/EDB <br /> ype of failure/discharge atastroph is long-term leakage verfill nknown1 10 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 �S of/Year ; '%6 verage Annual Precipitation = 4 10-25 <br /> -Site Wells) es o umber 8 Type Irr om I ub <br /> S Score S Score S Score <br /> istance to Well(s) from Tank ft; ft; ft - C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R onclition R condition R ondition <br /> J. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Semple (feet) >100 1.100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) �b 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) None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least gore than <br /> %x%%x None C� One /l one <br /> /oCOLUMN TOTALS>>>TOTAL POINTS � + d7 v <br /> + J7 <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS f9 pts or more 41 - 48 pts 40 pts or les <br /> k1 D DLtm 03.5 Porn 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 Result: ASOLINE1000 100 10 <br /> A%IMUM ALLOWABLE TPH LEVELS (PPM) <br /> I <br /> TPH <br /> IESEL 10,000 1000 100 / <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the teat 1 tial <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 /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure as o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE C011PLETED 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 7 y� <br /> .VALUATOR �I J <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />