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SAN JOAOUIN'C6JNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HNEIH DIVISION q <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 3 / <br /> 'AME OF FACILITY � �y�.� ti�i� WEEPS CODE <br /> DD RESSl 6 q ANK ID # <br /> TANK SIZE 500 UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? ks o ermit # acility Status Code oc.Soit/GW Cont es to <br /> Lnnber of Tanks at facility Be of Tanks(if available) ype of Tank Leel I Fbrgl I IS <br /> ngl Dual <br /> III. TANK HISTORY <br /> .is Tank tested? as 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 repaired7 <br /> ns repair done under inspect ion?TesFN0 ere soil samples analyzed? es 10 TXE PH PH-D b/EDB <br /> Type of failure/discharge otastrophic long-term leakage verfill nknown cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .oil Samples Received as o pth to Ground Water �S of/Year ; verage Annual Precipitation 4 10-25 <br /> e <br /> -Site well(s) es o umber & Type Irr om I ub <br /> S core S core S core <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C pts C pts <br /> 0 if 0 if 0 'f <br /> R ondition R ondition R ondition <br /> J. Site feature - Leaching Potential Analysis E is met E is met E 's 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) 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 4ore than <br /> xxxxx None -/ one one <br /> COLUMN TOTALS>>>TOTAL POINTS /D r /� ♦ A <br /> ample Result: (D TX OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> N'Dj 10f(� B T X E B i X E <br /> V MAXIMUM ALLOWABLE D-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Ret: ASOL(NE 1000 100 10 <br /> y� M AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> IESEL 10,000 1000 100 <br /> FOOTNOTES: ***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., store 0 points. If depth <c5 ft., do not use table. <br /> \2 if precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm ( <br /> diesel) <br /> . <br /> W _ <br /> VI. STAFF RECOMMENDATION/CONCSION 'rl / „ _ ce <br /> i <br /> 1. Are DTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure as o If Yes, Refer to Site Mitigation for Evaluation T X <br /> Rd VGi <br /> Vtl. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR � n <br /> -ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 40 /aT// <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />