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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE %�,4_ S ,� <br /> AME OF FACILITY 2• WEEPS CODE 1 I S <br /> DDRESS �_'�� ` •l f STANK ID # <br /> 'v' JTANK SIZE UEL TYPE Re <br /> 11. GENERAL SITE HIST RY <br /> ** <br /> Is permit current? es o ermit # acility Status Code oc.Soil/GW Cont 1Yes o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank teel Fbrgl IS <br /> ngL Dual <br /> III. TANK HISTORY <br /> as Tank tested? 1Yes I IN01 <br /> ailed precision test ? es 0 If yes, give date(s) <br /> as a repair made to the tank system? 1Yes No 1 11f yes, what was repaired? <br /> as repair done under inspection? es o ere soil samples analyzed? 1Yes I Jo I TXE PH-G I lr� <br /> PH-D I Io EDB <br /> ype of failure/discharge atastrophic long-term leakage F loverfill nknown 1 10ther: <br /> 1V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Ifes IxIN. epth to Ground Water of/Year (; verage Annual Precipitation = 4 10 25 <br /> n-Site Wells) es �' o umber & Type Irr om ub <br /> S core S Score S Score <br /> Distance to Well(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 ondition <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 r 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) /Ll None --- Unknown Dresent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 1xxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration �- <br /> f leachate (i.e., septic systems, water wells, ponds) <br /> None Unknown Dresent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> Pli 'ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 fs 40 pts or Less ', <br /> P� K -2 ,O1 1 ' �O3T11� B 1 TX E T E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 1. 1. NA\3 <br /> 11 ample Result: ASOLINE 1000 A Do 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPHDIESEL 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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yeso <br /> 2. Recommend Site Closure 1Y <br /> 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 YESJO <br /> )ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF ✓� ��—i L� <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />