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SAN JOAQUIN OY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA*DIVISION <br /> 4-3 � <br /> I. UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE Z <br /> AME OF FACILITY d <br /> CORD ID <br /> H <br /> ANK ID #UEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # - acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tank(if available) ype of Tank feel FbrgL HL Dual <br /> III. TANK HISTORY <br /> as Tank tested? eso ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? tes No f yes, what was repaired? <br /> as repair done under inspection? es I o ere 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 16DIR of/Year verage Annual Precipitation = 4 0-25 <br /> n-Site Wells) es o umber & Type 2 lirr om ub <br /> S Score S core S 3core <br /> -Vmf t <br /> istance to WeLI(s) from Tank ; ft; ft C 0 pis C pts C pts <br /> 0 if 0 1f 0 f <br /> R conditi on R ondition R ondition <br /> 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) >100 1-100 25-501 <br /> Fractures in subsurface (applies to foothills or mountain areas) O None I Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 Kxxxxxx 26-40N2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water welts, ponds) None Unknown resent <br /> pique site features: Recha a, coarse soil, or wells. At least ore than <br /> [MuncipaL=>2000 ft; esti-=>500 f irr/agri culcural=present] xxxxx None y one AAr one <br /> COLUMN TOTALS>>>TOTAL POINTS I C' * I * I <br /> ample Result: (B T % OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pt 40 pts or Less <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) B 50 50 EO .3 .3 1. 1. NAL <br /> ample Result: ASOLINE 1000 100 10 <br /> 15D �AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TpHIJ IESEL 10,000 1000 100 <br /> 7 ***If documented soil and/or ground water contamination is present, do no ete the leaching potential <br /> analysis. (i.e., site is currently on LOT 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 /> 7 *** <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPN Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es If Yes, Refer to Site Miti ati on for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED ATE CLOSU LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EM 23 80 (UGTWKSHT)\5/94 <br />