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SAN JOAOIIIN VWNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HL,IN DIVISION <br /> I- UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE ' <br /> AME OF FACILITY /C f WEEPS CODE <br /> DRESS �� ANK ID # <br /> ANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # IFacility Status Code _ SoiL/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) IT <br /> ype of Tank teel Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o If yes, give date(s) <br /> Jas a repair made to the tank system? as No f yes, what was repaired? <br /> as repair done under inspection? es q0 ere soil samples analyzed? es o TXE I PH-G I PH-D I b/EDB <br /> Type of failure/discharge atastrophic long-term leakage I verfill noun they: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water - of/Year 'fverage Annual Precipitation = 4 0-25 <br /> -Site WeLL(s) es o umber & Type Irr W ub <br /> S Score S core S 3core <br /> istance to WeLL(s) from Tank ft; ft; ft C 10 pts C pts C 3 pts <br /> 0 if 0 f 0 if <br /> R ondition R ondition 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 Sample (feet) -3S=a >100 1-100 - 25-501 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) Xxxx <10 9 10-25 xxxxxx 26-40L <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) �� None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. / At least ore than <br /> xxxx None / one one <br /> COLUMN TOTALS>>>TOTAL POINTS t I'll . <br /> ample Resu Lt: IS T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> Iv� " -" '�P�0> e T % E 8 T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1- NAL <br /> Sample Result: SOLINE 1000 100 10 <br /> AX IMUM 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., score 0 points. If depth <=5 ft., do not use table. <br /> L If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPM concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > A(Lowable Levels Yes o <br /> 2. Recommend Site Closureo es 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 O <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED / / <br /> AME OF <br /> I 4 n <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />