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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY x, x� WEEPS CODE <br /> DORESS 7 �TANK ID # <br /> TANK SIZE 00 �� UEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # acility Status Code oc.Soil/GW Cont as o <br /> umber of Tanks at facility he of Tanks(if available) IT <br /> ype of Tank IS Leel Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? esI1 IF I T o ailed precision test ? as o If yes, give date(s) <br /> as a repair made to the tank system? 1Yas No 1 11f yes, what was repaired? <br /> ns repair done under inspection? esere soil samples analyzed? es 10 TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term <br /> o leakage verfitl nknown 1 10 <br /> ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> mil Samples Received as INo epth to Grovel Water of/Year verage Annual Precipitation = 4 10-25 <br /> -Site Well(s) es y o umber 8 Type Irr cm ub <br /> S Score S core S Score <br /> istance to WeIL(s) from Tank ft; _ft; ft C 10 pts C pts C 5 pts <br /> 0 if 0 1f 0 if <br /> R ondition R ondition R onditfon <br /> V. Site Feature . Leaching Potential Analysis E is met E is met Es met <br /> inimum Depth to groundwater from the Soil Sade (feet) �_ s�� >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) O None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 AXXXXXX 26-40\2 <br /> nn-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 /> xxxxx None / one one <br /> Y� <br /> COLUMN TOTALS»>TOTAL POINTS �(� * �'J <br /> ample�Result: (B^J T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> O OI of B T X E T % E <br /> MAXIMUM ALLOWABLE B-T•X•E LEVELS (PPM) 1 50 50 50 37 3 1. 1. NA\3 \ <br /> 'amplesult:M 1 ���M A%IMUM ALLOWABLE TPH LEVELS (PPM) ASOL(NE 1000 100 10 <br /> G� <br /> MOA <br /> IESEL 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 1f precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXSE 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 I IN01 <br /> 2. Recommend Site Closure Fesl o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. 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 40 <br /> )ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />