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SAN JOAOUIN)UNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HewtTH DIVISION <br />I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br />AME Of FACILITY Gi)l� s(6 IG aI WEEPS CODE 18 31 <br />DDRESS13%,5 tif. j ©✓t'T7Jvl j TANK ID # <br />TANK SIZE 000 IF <br />UEL TYPE e <br />ll. GENERAL SITE HISTORY <br />permit current? es o X ermit # acitity Status Code oc.Soil/GW Cont es o <br />nber of Tanks at facility ge of Tanks(if available) IT <br />ype of Tank IS tee Fbrgl y ngl I Dual <br />'as Tank tested? <br />es <br />'ES <br />o <br />IND <br />ailed precision test ? <br />es <br />I <br />IN01 <br />verage Annual Precipitation <br />If yes, give date(s) <br />4 <br />as a repair made to the tank system? es No 1A 11f yes, what was repaired? <br />n -Site Well(s) <br />ns repair done under inspection? <br />es No <br />ere soil samples analyzed? es <br />AME OF <br />:VALUATOR <br />to <br />TXE <br />PH -G <br />PH -D <br />b/EDB <br />Score <br />10 pts <br />if <br />ondition <br />is met <br />Type of failure/discharge <br />Score S <br />9 pts C <br />if 0 <br />condition R <br />is met E <br />atastrophic <br />long-term leakage <br />I <br />verfiIt <br />lo <br />X <br />lunknown <br />ther: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />oil Samples Received <br />es <br />'ES <br />IN. <br />IND <br />epth to Ground Water <br />EFERRED TO SITE MITIGATION FOR EVALUATION <br />cf/Year <br />verage Annual Precipitation <br />= <br />4 <br />10-25 <br />n -Site Well(s) <br />es <br />o <br />AME OF <br />:VALUATOR <br />qumber & Type <br />Irr <br />om <br />ub <br />S <br />0 <br />R <br />E <br />Score <br />10 pts <br />if <br />ondition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score S <br />9 pts C <br />if 0 <br />condition R <br />is met E <br />Score <br />5 pts <br />if <br />ondition <br />s met <br />istance to Well(s) from Tank <br />ft; ft; ft <br />Site Feature - leaching Potential Analysis <br />inimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />1-100 <br />25-50\1 <br />ractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />resent <br />verage Annual Precipitation (inches) <br />Kxxxxx <br /><10 <br />9 <br />10-25 Axxxxxx <br />26-40\2 <br />nn -Made conduits which increase vertical migration <br />f leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />resent <br />Inique site features: Recharge area, coarse soil, nearby wells. <br />xxxxx <br />None <br />Cl <br />At Least <br />one <br />lore than <br />one <br />COLUMN TOTALS»>TOTAL POINTS <br />I� <br />+ <br />+ S <br />3 <br />7 <br />'ample Result: (B T X OR E) <br />i <br />RANGE OF TOTAL POINTS <br />P pts or more <br />41 <br />48 pts 40 pts or less <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />B <br />1 <br />1 T <br />50 <br />X <br />50 <br />E <br />SO <br />B <br />3 <br />T <br />3 <br />X <br />1. <br />E <br />1. NA\3 <br />-ample Result: GASOLINE <br />64 TPH--�—, AXIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL <br />1000 <br />100 10 <br />10,000 <br />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 < 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 pp(n (diesel). <br />VI. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br />2. Recommend Site Closurees I o If Yes, Refer to Site Mitigation for Evaluation <br />VII, REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR X-4 <br />ONCUR WITH STAFF <br />RECOMMENDATION FOR CLOSURE <br />'ES <br />IND <br />EFERRED TO SITE MITIGATION FOR EVALUATION <br />ES <br />JO <br />)ATE REFERRED <br />/ / <br />ATE CLOSURE LETTER MAILED <br />AME OF <br />:VALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />EH 29 80 <br />