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SAN JOAQUIN tleNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE* DIVISION / <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> qME OF FACILITY < EEPS CODE <br /> DODRESS NJ- I `/m� ANK ID # <br /> ' TANK SIZE IFUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> la permit current? es o ermit # acility Status Code oc.Soi l/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank teel brgl ngl I Dual <br /> 111. TANK HISTORY <br /> as Tank tested4 es o ailed precision test T es o If yes, give date(s) <br /> as a repair made to the tank system? es No I f yes, what was repaired? <br /> ns repair done under inspectionT es 1 401 Per soil samples analyzed? es 10 TXE PH•G PH-D b/EDD <br /> ype of failure/discharge atestrophie long-term leakage I verfill nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oar <br /> oil Samples Received es X o epth to Ground Water of/Year verage Amuat Precipitation = 4 10.25 <br /> •Site Wel I(a) es 7 o umber 8 Type Irr om ub <br /> Score S core S core <br /> istance to Well(s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 if 0 if 0 if <br /> R ondi ti on R onditI on R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1.100 — 25.50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) ld None _ Unknown — Present <br /> verage Annual Precipitation (inches) xxxxxx 00 9 10.25 xxxxxxx 26.40\2 <br /> an-Made conduits which increase vertical migration <br /> I leachate (i.e., septic systems, water welts, ponds) None Unknown Present <br /> inique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxx None one one <br /> "/1�0J <br /> COLUMN TOTALS>>>TOTAL POINTS p`t_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 /> PC:) ct moo" MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: ASOLINE 1000 100 10 <br /> /yam AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> ID I 'TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do 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 c 25 ft., score 0 points. If depth c=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 TPN Concentrations > Allowable Levels Yes H x <br /> 2. Recommend Site Closure es X o If Yes, Refer to Site Mitigation for Evaluation <br /> Vil. REVIEW EVALUATION - TO BE C014PLETEO 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 /> G / <br /> .VALUATOR � ( 1 <br /> 3/P(`�i <br /> � <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />