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SAN JOAQUIN CCUNI,. 7UBL1C HEALTH SERVICES/ENVIRCNMENTAL HEALTH. Islam F <br /> ), UGSf WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> nME OF FACILITY C'.��'ra lQ-���, n�/�, i i� ILi L' CCiTf76 EEPS CODE <br /> nORESS ' bloc berc -51 S7rII GK m ANK 10 X <br /> ANY SIZE IOC Cu UEL TYPE Di85Z� <br /> It. GENERAL SITE HISTORY <br /> Is permit current] es o ermit # - acil ity Status Code Q I oc.s it/GW Cont es o <br /> umber of Tanks at facility 3 ge of Tanks(if available) (�� - yPe of Tank feel lvlFhrgl rql Dual <br /> III. TANK HISTORY <br /> as Tank tested7 as o ailed precision tes 7 es o If yes, give date(s) <br /> Ps a repair made to the tank system? es No f yes, what was repaired? <br /> 'os repair done under inspection7 as o ere soil samples analyzed7 es o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic Long-term leakage I verfill nknown cher: <br /> o. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to GrogWalerT ver age Amual Precipitation 4 0-25 <br /> )n-Site Well(s) es o umber 8 Type core S core 5 core <br /> istance to Wells) from Tank ft; 0 pts C pts C pts <br /> if 0 if 0 if <br /> oditian it ondI tIon R ordition <br /> ture -ELeaching Potential Analysis is met E is met E is met <br /> FinEi� Depth to dwater frau the Soil Sample Veet) >100 1.100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> vcrage Annual Precipitation (inches) xxxxxx <10 9 10-25 Kxxxxxx 26.40\2 <br /> !+in•Hade conduits which increase vertical migration <br /> -f Leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> least are than <br /> e site features: Recharge area, coarse soil, nearby wells. At one one <br /> xxxx None <br /> COLUMN TOTALS»>TOTAL POINTS + <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 X E B T X E <br /> HAXIHLH ALLOWABLE B•T•X•E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. 4A\3 <br /> amQLe Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) 100 <br /> TPH IESEL 10,000 1000 <br /> COINOTES: ---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 /> '11, STAFF RECCFWENOATION/CCNCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o I£ Yes, Refer to Site Hiti gation for Evaluation <br /> REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> -ONCLR W11HSTA F RECCHMENOAT ION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / 7 / ATE CLOSURE LETTER MAILED y / <br /> LAME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />