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SAN JOAQUIN JNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEke(H DIVISION u <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY EEPS CODE 3 (/ <br /> DDRESS ?L) IT <br /> ANK ID # <br /> TANK SIZE ] 00 UEL TYPE q/L_ <br /> IT. GENERAL SITE HISTORY <br /> Is permit cuo ermit # acility Status Code oc.Soii/GW Cont as 10 <br /> rrent? es <br /> +umber of Tanks at facility he of Tanks(if available) IType of Tank IS <br /> teel Fbrgl I IS <br /> ngl Dual I <br /> III. TANK HISTORY <br /> ns Tank tested? es o IF ailed precision test ? as o If yes, give dates) <br /> as a repair made to the tank system? 1Yas No 1 11f yes, what was repaired7 <br /> ns repair done under inspection? as No ere soil samples analyzed? 1Y <br /> as 1 10 1 TXE PH-G PH-D b/EDD <br /> ype of failure/discharge atastrophic tong-term leakage verfiLl nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Foil Samples Received as o epth to Ground Water of/Year S /; verage Arcual Precipitation = 4 10-25 <br /> -Site Wells) as I o umber & TypeIrr om I ub <br /> S Score S Score S Score <br /> istance to WeIL(s) from Tank ft; ft; ft C 10 pis C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R onditi on R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) _l0 >100 61 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 /> nn-Made conduits which increase vertical migration C <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown ,J resent <br /> )nique site features: Recharge area, coarse soil, nearby Wells. At least lore than <br /> xxxxx None / one 7�/� donee <br /> p <br /> COLUMN TOTALS>>>TOTAL POINTS 1b ♦ { O f <br /> ample Result: (B T % OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> /I/D ��L a��� 0 T X E B T X E <br /> MA%IMUM ALLOWABLE B•T•X•E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Res}Il It: ASOLINE 1000 100 10 <br /> ��NN � ' �� A%IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH 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 LOT 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 /> VI. STAFF RECOMMENDATION/CONCLUSION / P <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes <br /> I2. Recommend Site Closure Yes I �!o I �If Yes, Refer to Site Mitf gati on for Evaluation to 9s <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 JO <br /> ES <br /> >ATE REFERRED F ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VALUATOR �� 6✓L �-�tJ <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />