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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEIICTH DIVISION q <br /> I' UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY >1 WEEPS CODE 1 /�2 VV <br /> DD RESS 1L4 # <br /> ANK S12E 3S� UEL TYPE -✓� ` <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # acility Status Code oc.Soit/GW Cont os 10 <br /> Ember of Tanks at facility) be of Tanks(if available) ype of Tank teal Fbrgl ngl Dual <br /> Ill. TANK HISTORY <br /> plsa,repal,r <br /> nk tested? es o ailed precision test ? es o If yes, give date(s) <br /> made to the tank system? es No f yes, what was repairedpar one under inspection? es oere soil samples analyzed? es Io TXE PH-G PH-D b/EDBf ailure/discharge atastrophic long-term leakage verfill nknown ther: <br /> I lo <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> mil Samples Received es I o epth to Ground Water 156 of/Year m),k ; verage Annual Precipitation A= 4 10.25 <br /> -Site WeII(s) es o umber 8 Type 11 r om I ub <br /> S Score 5 core S Score <br /> istance to Wetl(s) from Tank ft; ft; ft C 10 pts C pts C 5 pts <br /> 0 if 0 if O if <br /> R onditi on R ondition R ondition <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) 50 >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 X10 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 /> lnique site features: Recharge area, coarse soil, nearby wells. p At leas[ 4ore than <br /> exx'x\\xx None I one one <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 /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> -ample Res It: ASOLIK'E 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> IESEL 10,000 1000 100 <br /> OOTNOTES: ***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 c 25 ft., score 0 points. If depth c=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 Yes Io <br /> I2. Recommend Site Closure 1Y es 00 If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE C0MPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE 'ES I IND <br /> EFERRED TO SITE MITIGATION FOR EVALUATION ES JO <br /> )ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF I <br /> :VALUATOR ^ <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />