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SAN JOAQUIN CLU•PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH .,VISION <br /> I' UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE B /„ <br /> AME OF FACILITY . !_. WEEPS CODE /Z . <br /> Lf <br /> OGRESS r� �n - <br /> ICA X32 ���c ANK ID X O <br /> LANK SIZE UEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Q .• <br /> Is permit current) as o ermit q - acility Status Code O oc.soi /GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank teel Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? as o ailed precision test es !f yes, give date(s) <br /> Jas a repair made to the tank system? es No f yes, chat uas repaired) <br /> Jas repair done under inspection) as ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> ype of failure/discharge otos trophic long-term leakage verfill nknoun the r: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es V epth to Ground Water 'oi of/Year ; 8(P verage Annual Precipitationr40-25I-Site Wells) es o umber 8 Type Irr cm ub 11S core S core S is[ante to Wells) from Tank f ft; ft; ft C 0 pts C 9 pts C 0 if 0 1f 0 R ondition R ondition R Site Feature - Leaching Potential Analysis E is met E is met E <br /> inimxm Depth to groundwater from the Soil Sample (feet) �p%g s Z' >'001-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxxx <10 9 10-25 xxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> nique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + + <br /> ampl Res�NI(B T X OR E) RANGE OF TOTAL POINTS .9 pts or more 41 - 48 pts 40 pts or less <br /> x[Can+po51{e).2.gUAI MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> ample Result- ASOLINE 1000 100 10 <br /> TP/+-D — IB fM 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 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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDAT ION/CCNCLUS ION L = to <br /> 1. Are BTX $ E or TPH Concentrations > Alt�IYe, <br /> evels Yes o <br /> 2. Site Closure es o , Referto Site Mitigation for Evaluation — 2.1 Qf^^ X= 1-2- <br /> Recommend I r <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR LedO <br /> . ( <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION 0 <br /> )ATE REFERRED b / / ATE CLOSURE LETTER MAILED <br /> LAME OF <br /> VALUATCR <br /> EH 23 30 (UGTWKSHT)\5/90 <br />