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� 1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALT VISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> 1. <br /> / WEEPS CODE D� <br /> AME OF FACILITY i��/5�-f� G ff' ANK 10 # 3c/ <br /> DRESS <br /> ANK SIZE /s o UEL TYPE �Pu P C <br /> •k <br /> 11. GENERAL SITE HIS DRY <br /> es o ermit # <br /> Is permit currentY <br /> acility Status Code 5 3 oc.Soil/GW Cant s o <br /> umber of Tanks at facility <br /> ge of Tanks(if available) ype of Tank teal Fbrgl ngl Dual <br /> III. TANK HISTORY I <br /> o If yes, give date <br /> ailed precision test i es <br /> as Tank tested9 as o <br /> as a repair made to the tank system? as No yes, what was repo ired7 PH <br /> as repair done under inspection? as o ' <br /> ere soil samples analyzed? <br /> o TXE -G PH-D b/EDB <br /> ype of failure/discharge ate rophic Long-term leakage verf' nknown then: <br /> IV. REMOVAL HISTORY (ATTACH INSP TION REPORT FOR SITE DETAILS/COLLEC DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received as o epth to Ground Water /tj of/Year <br /> "X/n verage Annual Precipitation = 4 0-25 <br /> n-Site Wells) as o umber & Type Z Irr , om ub S core S cor <br /> S core s <br /> ft C 0 pts C pts o f <br /> istance to Wel l(s) from Tank ],,(L/L/ ft: _f t) 0 if 0 if <br /> R ondition R ondition R ordition <br /> Site Feature - Leaching Potential Analysis <br /> E is met E is met s met <br /> inimum Depth to groundwater from the Soil Sample (feet) 2' <br /> >100 1-100 25-50L <br /> ractures in subsurface (applies to foothills or mountain areas) <br /> None nknown resent <br /> verage Annual Precipitation (inches) <br /> xxxxx <10 10.25 mxxxx 26-401 <br /> on-Made conduits which increase vertical migration N Unknown resent <br /> f Leachate (i.e., septic systems, water wells, ponds) <br /> At least ore than <br /> nique site features: Recharge area, coarse soil, nearby wells. x x None one one <br /> yCOLUMN TOTALS»>TOTAL POINTS <br /> ample Result: (B 1 X OR E) RANGE OF TOT POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> /�O✓i —P>-�` ' B T X E B T X E <br /> MAXIMUM ALLOL7ABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1• 1• NAL <br /> ASOLINE 1000 100 10 <br /> ampl' IESEL 10,000 1000 e Result: i <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) 100 <br /> ,t �V�.�_L0 <br /> Il,..�(�,H � <br /> fes/ b� •••If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> OOTNOTES: <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water. <br /> L If depth is > 5 ft. end < 25 ft., score 0 points. 1f depth <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. 7 <br /> \3 Levels for BTX&E are not applicable at a TP O; entration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION .lLh 0- "k"(L a r <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes Imol <br /> 2. Recommend Site Closure y <br /> es o I 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 ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VAWATOR cX-dam•✓ <br /> EH 23 80 (UGTWKSHT)\5/90 <br />