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SAN JOAOUIN CDUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL i� nLTH DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY dnaa WEEPS CODE <br /> DRESS ANK ID # <br /> TANK SIZE UEL TYPE <br /> IT. GENERAL SITE HIS RY <br /> ** <br /> Is permit current? es o ermit # - acuity Status Code oc.Soi l/GW Cont as FT07 <br /> umber of Tanks at facility ge of Tanks(if available) .��� ype of Tank teel FbrgL I IsngL Dual <br /> III. TANK HISTORY <br /> Was Tank tested? es o L4ailed precision test 7 es o If yes, give date(s) <br /> Was a repair made to the tank system? es No f yes, what was repaired? <br /> Was repair done under inspection? es oere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verfill nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water I Ilef/Year verage Annual Precipitation A= 4 0-25 <br /> n-Site Well(s) es o umber & Type Irr I am I ub <br /> ��11 S core S core S core <br /> oc <br /> istance to We[L(s) from Tank 2 ft; _ ;AQD ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> Ii nimum Depth to groundwater from the Soil Sample (feet)FO_ i31 >100 1-100 S 25-501 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxx 26-40L <br /> Ian-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown 5 resent <br /> pique site features: Recharge area, coarse soil, nearby wells. �j At Least ore than <br /> xxxxx None 'I one one <br /> COLUMN TOTALS»>TOTAL POINTS A I + I O <br /> Sample 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 % E <br /> IV IJ MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 SO .3 .3 1. 1. NA 3 <br /> Sample Result: ASOLINE 1000 100 10 <br /> AXI MUM ALLOWABLE TPH LEVELS (PPM) <br /> __ALQTPH 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 /> J2 If precipitation is > 40 inches, score 0 points. <br /> 1 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). ' <br /> VI. STAFF RECOMMENDATION/CONCLUSION J Od S or <br /> 1. Are BTX & E or TPH Concentration > Allowable Levels Yes <br /> 2. Recommend Site Closure es o 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 /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />