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00 ! <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION q <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY ��yy &ux.0 tYLG WEEPS CODE 00 6 <br /> DRESS CJ < L,,.,l lj GA I 1 n ANK 10 <br /> TANK SIZE UEL-TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current7 as o ermit # - acility Status Code JCS 0C.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) UrI�L ype of Tank Leel jhrgL I ngl ,-Dual <br /> 111. TANK HISTORY 1,"C),/,P— . g$ <br /> as Tank tested? es o ailed precision test ? es o 1f yes, give date(s) <br /> Jas a repair made to the tank system? IYes Na f yes, what was repaired? <br /> as repair time under inspection? as 1 40 ere soil samples analyzed? as I ao T%E •G 1_4WD b/EDB <br /> Type of failure/discharge I atastrophic Long-tern Leakage verfillI It noun 1 10 <br /> ther: <br /> 1V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Receivedes o epth to Ground Water t5 of/Year verage Annual Precipitation R= 4 0-25 <br /> n•Site WeI L(s) es o umber 8 Type Irr an ub <br /> S core S core S 3core <br /> -stance to WeIL(s) from Tank ft; ft; ft C 10 pts C pts C 5 pts <br /> 0 if 0 1f 0 if <br /> R condition R ondition R ondition <br /> V. Site Feature - Leaching Potential Ana Lysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) jj5,(p; 5 >100 1-100 25.501 <br /> Fractures in subsurface (applies to foothills or mountain areas) IC) None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxxmx 26-401 <br /> Ian-Made conduits Which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) None Unknown Dresent <br /> pique site features: Recharge area, coarse soil, nearby wells. At Least ore than <br /> xxxx None 9 one one <br /> COLUMN TOTALS»>TOTAL POINTS (G + t o + p g <br />^'T4 amplte\Result: (B T X OOr 'R �E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> @ to, N� 0L pr'yB T X E 8 T % E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> --F <br /> Sample Result: SOLINE 1000 100 10 <br /> IMUN ALLOWABLE TPH LEVELS (PPM) <br /> t4D ' Spj9yVl 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 wa <br /> ]1 If depth is > 5 ft. and < 25 ft., score 0 points. tlf depth <=5 ft., do not use table. APPS OX <br /> 12 If precipitation is > 40 inches, score 0 points. <br /> L Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION 1�X1�G( o CWLAty tv'cfl l 0b5e✓ <br /> _Q'1 'tl r-¢ tcr�lG ✓ar^oJc:.Q <br /> 1. Are BTX 8 E or TPM Concentra ti oru > Allowable Levels Yes o <br /> 2. Recommend Site Closure es I V�o I If Yes, Refer to Site Mitigation for Evaluati on U <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 />