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SAN JOAQITTN COUNTY PUBLIC HEALTH SER • <br /> 1. VICES/ENVIRONMENTAL HEALTH DIVISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> AME OF FACILITY ^ ! <br /> kf 7, <br /> n �!�f;1 .% uEEPS CODE 1p7 <br /> DRESS � <br /> TANK SIZE CC �� TANK ID # ;7/ �� / <br /> J �(��- UEL TYPE �, l , _/� <br /> 11. GENERAL SITE HIS ORY �l <br /> Is permit curre2at <br /> es i o ermit # - / 7/ acilit Status Code ** <br /> 1 y � -_ oc.Soil/GW Cont es o <br /> weber of Tanksacility ge of Tanks(if available) <br /> ype'of Tank teel Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es V' o ailed precision test ? es o <br /> l If yes, give dates) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es qo ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> IT ype of failure/discharge atastrophic long-term leakage verfill nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es v/ oepth to Ground Water of/Year <br /> verage Annual Precipitation = 4 0 25 <br /> n-Site WeLL(S) es o umber $ Type Irr om ub <br /> istance to Wells) from Tank ft; _ft; S core S core S core <br /> t; ft C 0 pts C 9 pts C pts <br /> 0 if 0 if 0 if <br /> V. R ondition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is meet E .s met <br /> inimum Depth to groundwater from the Soil Sample (feet)? .- >100 1-100 <br /> 25-SOL <br /> ractures in subsurface (applies to foothills or mountain areas) r <br /> None Unknown resent <br /> verage Annual Precipitation (inches) xxxxx <10 9 <br /> 10-25 KXXXXXX 26-4012 <br /> Ian-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) None <br /> Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. !J <br /> At least 1 <br /> 4ore than <br /> xxxxx None f one <br /> one <br /> COLUMN TOTALS>>>TOTAL POINTS + r ; + ' + Qr <br /> ample Result: (B T X OR E) O <br /> RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 11 50 SO 50 .3 .3 11. 1. NA,3 <br /> ample Result: ASOLINE 1000 100 <br /> A�+ AXIMUM ALLOWABLE TPH LEVELS (PPM) 10 <br /> / 1, TPN 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 /> 11 If depth is > 5 ft. and < 25 ft., score 0 points. if depth <=5 ft., do not use table. <br /> 12 If precipitation is > 40 inches, score 0 points. <br /> 13 Levels for BTX$E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o y I <br /> I IN <br /> 2. Recommend Site Closure es �W' o If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR 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 /> =VALUATOR ; <br /> EH 23 80 (UGTWKSHTA5/90 <br />