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SAN JOAQ* COUNTY PUBLIC HEALTH SERVICES/E.NVIRONMENTAL77,'cALTH DIVISION <br /> I. UST WORKSHEET FOR SITE CLOSURE EVALUATIONATE <br /> AME OF FACILITY G G '— v �� S. �. ECCRD [0 fL <br /> DRESS ANK 1D 'J 3 O'1 <br /> TANK SIZE /L TYPE A�" d� <br /> lI. GENERAL SITE HISTORY <br /> s permit current? eso ermit i - acility Status Code cc.soil/GU Cant es o <br /> unber of Tanks at facility ge of Tank(if available) ype of Tank tee4 rgl l I Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o If Yes, give date(s) <br /> as a repair made to the tank system? kaS No f yes, what was repaired? <br /> Pas repair done under inspection? es o ere sail samples analyzed? as o TXE � PM-G PH-O b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill I Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Yater ��'ef/Year �' verage Annual Precipitation = 4 0-25 <br /> -Site Welts) es o iilmmber & Type Irr pan ub <br /> 5 core S Scare S Score <br /> istance to WetL(s) from Tank I ft; ft; ft C 0 pts C 9 pts C i pis <br /> 0 f 0 if 0 if <br /> R ondition R condition R ondition <br /> Site Feature - Leaching Potential Analysis - E s met E is met E is met <br /> inioum Depth to groundwater from the Sail Sanple (feet)/O— 7,5 >100 1-100 1 6 25-50L <br /> Fractures in subsurface (applies to foothills or mountain areas) O None Unknown resent <br /> Average Annual Precipitation (inches) <10 9 10-25 26-407 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None q Unknown Present <br /> pique site features: Recharge area, coarse sail, or wells. p At least 4ore than <br /> (Muncipal=>2000 ft; domestic1500 ft; irrjagricuLturaI=preseMt3 KXXXXX None 1 one we <br /> COLUMN TOTALS»>TOTAL POINTS 11D ' i _�� <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40,pcs or less <br /> B T X E 3 T Xe <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 17 1. NA�3 <br /> Sample Result: SOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTES: —If documented soil and/or ground water contamination is present, do not canplete the Leaching-o"Erit-fal <br /> analysis. (i.e-, site is currently on UGT Contamination List for soil or growl water.) <br /> \1 if depth is > 5 ft. and < 25 ft., score 0 points. If depth c5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, scare 0 points. <br /> L Levels for STX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Arc BTX & E or TPH Concentrations > Allowable Lwels es o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 �tEFERRED TO SITE MITIGATION FOR EVALUATICN kES O <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />