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SAN JOAQUIN�OUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H�?ICTH DIVISION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION IDATE I i S /U <br /> AME OF FACILITY �._: WEEPS CODE <br /> DDRESS / - - ANK ID W <br /> ANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> ** <br /> Is permit current? es o ermit N acility Status Code oc.Soi l/GW Cont es 110TH <br /> +umber of Tanks at facilityl he of Tanks(if available) ype of Tank ISLeel Fbrgl I ISNt I Dual <br /> III. TANK HISTORY <br /> as Tank tested? Ifes I IHOI ailed precision test ? as I INQ1 if yes, give dates) <br /> as a repair made to the tank system? as No 1 11f yes, what was repaired? <br /> Jas repair done under inspection? es 40 ere soil samples analyzed? as to TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfilt nkncwn 1 10 <br /> then. <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> soil Samples Received as o IDepth to Ground Water /-7, of/Year11( 1, ;i is ver0ge Annual Precipitation = 4 10-25 <br /> -Site Welt(s) as o umber 8 Type Irr pm ub <br /> S core 5 i Score S Score <br /> Distance to Wells) from Tank ft; fry ft C 10 pts C 9 pts L 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R ordition <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) >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) 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 ore than <br /> xxxxx None one /one <br /> COLUMN TOTALS>>>TOTAL POINTS J + <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> B T % E B T X E <br /> A 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 /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> UD IESEL 10,000 1000 100 <br /> OI OILL, TPN_ <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do riot complete,rhe Leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for spit_ 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 TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1, Are BTX 8 E or TPN Concentrations > Allowable Levels Y0s 0 <br /> I2. Recommend Site Closure lyes I �11 I / If Yes, Refer to Site Mitigation for Evaluation <br /> VII, REVIEW EVALUATION - TO BE C014PLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR 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 /> Ex 29 80 <br />