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SAN JOAQUIN STY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HDIVISION <br /> 1 UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY YAG;` ' WEEPS CODE .3� <br /> DD RESS ` S +`�! (�fl �� ANK ID # <br /> TANK SIZE UEL TYPE <br /> If. GENERAL SITE Hf ORY <br /> ** <br /> Is permit current? es o ermit # IF <br /> acility Status Code oc.Soil/GW Cont es� )o <br /> Ember of Tanks at facility) Be of Tanks(if available) ype of Tank tee) Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? 1Yas No1 11 f yes, what was repaired? <br /> ns repair done under inspection) es No ere soil samples analyzed? es 10 TXE IT <br /> PH-G PN-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 /> ',oil Samples Received as I o epth to Ground Water of/Year verage Annual Precipitation A= 4 10-25 <br /> n-Site Wett(s) as -,� o umber 8 Type Irr 0M ub <br /> S Score S Score S Score <br /> istance to Wetl(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ordition <br /> 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) 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 /> ! leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> axxxxx None ry' one one <br /> COLUMN TOTALS>>>TOTAL POINTS CO + (Q + 3 -3 <br /> 'ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 • 48 pts 40 pts or ass <br /> B T X E B i X E <br /> l7L MAXIMUM ALLOWABLE D•T•X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> 'ample Result: ASOLINE 1000 100 10 <br /> N�pJ— 4 O ef� D L- AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> I 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 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 STXBE 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 TPH Concentrations > Allowable Levels Yes o <br /> I2. Recommend Site Closure )Yes I �o I f*If Yes, Refer to Site Mitigation for Evaluation <br /> Vfl. REVIEW EVALUATION - TO BE COMPLETED BY A SIUPERVISOR/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 - /6'//� ( <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />