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SAN JOAQUIN CMJWSLIC HEALTH SERVICES/ENVIRCHMENTAL HEALTNO SION M / <br /> I. UGSi WORKSHEET FOR SITE CLOSURE EVALUATION ATE CCJL <br /> nnE OF FACILITY )�� L2i ./,o EEPS CODE �� <br /> OORESS ��� �� �'�� .t:'(..�fl'iL� 1.5.7 ANK ID B <br /> IANK SIZE UEL TYPE <br /> II. GENERAL SITE HISTORY !• <br /> Is permit current7 es o efmit N atilt ty Status Code L�; oc.soi /GW Con es o <br /> anter of tanks at facility ge of Tanks(if available) .2-V /5 ype of Tank teel V Fhrgl ngl ✓Dual <br /> III. TANK HISTORY <br /> as Tank tested? If es o L, ailed precision tesc11%7 es o If yes, give date(s) <br /> as a repair made to the tank system7 es No L f yes, what was repaired? <br /> 'as repair done under inspection? es I-i o ere sail samples analyzed? es o TXE PH-G PH•D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown cher: <br /> AV. REMOVAL HISTORY (ATTACH INSP TION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water /D of/YearMlwR <br /> Annual Precipitation L 0-25 <br /> -Site Wells) es o umber 8 Type Irr an ub <br /> care S core <br /> istance to WeIL(s) frau Tank N ft; ft; ft pts C pts <br /> if 0 if <br /> ondition R ordition <br /> J. Site Feature - Leaching Potential Analysis is nw:t E 's met <br /> inimum Depth to grourdwater from the Soil Sample <feet) �(��.�3�c`3 7 >100 1-700 25.50\1 <br /> ractures in subsurface (applies to foothills or noun tain areas) Hone Unknown resent <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 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 /> ni we site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> zxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS * + <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> (f, IV <br /> (� B T X E B T X E <br /> rl 11 I° •l/- �iM a5 MAXIMUM ALLOWABLE 3•T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> ample Result: DP_kt - ASOLINE 1000 100 10 <br /> AX ITUM ALLOWABLE TPH LEVELS (PPM) <br /> • TpH O)- IESEU 1 10,000 1000 100 <br /> COTNOTES: •"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 RECCFMENDAT ION/CCNCLUSION <br /> 1. Are BTX $ E or TPN Concentrations > ALL able Levels Yes o 113L41 -: <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation 15`1I'N <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR ju.V +0 tp u0 /•" , &-j <br /> .OHCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATIONFFORR<•EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> LAME OF <br /> :VALUATCR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />