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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY WEEPS CODE <br /> *DRESS 1Z2 V ,`w- �! .y� ( ANK ID # <br /> TANK S12E UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit currents es o ermit N - acility Status Code i/ oc.Soil/GW Cont es o <br /> umber of Tanks at facility �� ge of Tanks(if available) ype of Tank. Leel Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested? es o I % ailed precision test 7 as ilo 1f yes, give date(s) <br /> as a repair made to the tank systems Yes No f yes, what was repaired? <br /> Jas repair done under inspection? es No ere soil samples analyzeds as o TXE PH•G PH-D b/EDB <br /> Type of failure/discharge atastrophic tong-teen leakage verfill nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o I epth to Ground Water %, of/Year ) verage Annual Precipitation = 4 0-25 <br /> )n-Site Wells) es I o -umber 8 Type Irr am ub <br /> S 3core 5 core 5 core <br /> ?stance to Well(s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 if 0 if O if <br /> R ond'Ition R ordition R ondition <br /> J. Site Feature . Leaching Potential Analysis E is met E is met E is met <br /> inimun Depth to groundwater from the Soil Semple (feet) >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 T one one <br /> COLUMN TOTALS»>TOTAL POINTS 2j -' ' ) <br /> omple_ResulI (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B T X E 8 T %_ E <br /> ---G o3 z p+ MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1.. 1. NA�3 <br /> ample Result{ ASOLINE 1000 100 10 <br /> L k+ Il AXI MUM ALLOWABLE TPH LEVELS (PPM) 100 <br /> �5 TPH IESEL 10,000 1000 <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 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 /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recomoend Site Closure as o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE CC14PLETED BY A SUPERVISOR/SENIOR <br /> ONLUR 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 /> "VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />