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SAN JOAQ COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAOEALTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE W';' <br /> AME OF FACILITY e'x� WEEPS CODE <br /> DRESS �s ANK ID p 3 3 ­ /—, <br /> (ANK S12E jqDO� UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? Ifes o ermit M - aciLity Status Code I C� oc.Soi l/GW Cont as o <br /> umber of Tanks at facility ae of Tanks(if evai Lable) ype'of Tank teel Fbrgl I knal Dual <br /> 111, TANK HISTORY <br /> Jas Tank tested? es o ailed precision test ? as o 1f yes, give date(s) <br /> Jas a repair made to the tent system? as No f yes, what was repaired? <br /> Jas repair done under inspection? es o ere soil samples analyzed? es o TRE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic on term leakage verfiLl noun they: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soft Sarples Received es o epth to Ground Water 70of/Year R6 ; verage Annual Precipitation = 4 0.25 <br /> -Site Wells) es o umber 8 Type 11 r om ub <br /> S core S core S core <br /> _ istance to Wells) from Tart I_15—f t; ft; ft C 10 pts C 9 Pts C 3 pts <br /> 0 if 0 if 0 if <br /> R ondition IT condition R ondition <br /> J. Site Feature - Leaching Potential Analysis E is mkt E is met E is met <br /> inimua Depth to groundwater frac the Soil Saiple (feet) >100 1-100 25-50L <br /> ractures in subsurface (applies to foothills or mountain areas) O None Unknown resent <br /> verage Annual Precipitation (inches) xxxxx <10 9 10.25 xxxxxx 26.40E <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At Least 4ore than <br /> xxxx None one l� one <br /> COLUMN TOTALS>>>TOTAL POINTS I + au 7 + ✓ ![�0— <br /> ample Result: (B T % OR E) RANGE OF TOTAL POINTS 9 pts or mare 41 - 48 pts 40 pts or less <br /> 9K� Y lir ND <br /> B T % E B T X E <br /> J <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 5g 50 .3 .3 1. 1. NAL3 <br /> ample Result: ASOLINE 1000 100 10 <br /> LT <br /> K A%IFIl1N ALLOWABLE TPH LEVELS (PPM) <br /> PN IESEL 10,000 1000 100 <br /> FOOTNOTES: ...If documented soil and/or ground water contamination is present, do not caiplete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamf nation List for soil or ground water.) <br /> 11 If depth is > 5 ft, end < 25 ft., score 0 points. If depth r_5 ft., do not use table. <br /> 2 If precipitation is > 40 inches, score 0 points. <br /> Z Levels for BT%8E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPN Concentrations > Allowable Levels Yes o <br /> -- - <br /> I2. Recommend Site Closure as o v, If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 I EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED / / <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />