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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION , <br /> 1, UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> • AME OF FACILITY M P �{ L „ 'WEEPS CODE <br /> DRESS 'L/I ! 5e /�OtG I//� Tl''\Xit/t� TANK 10 X I Z� <br /> LANK SIZE 'Q () UEL TYPE /fP��p� �/� ) 77 'I3 <br /> 11. GENERAL SITE HISTORY <br /> ff <br /> Is permit current7 es o errmit M - acility Status Code oc.Soil/GW Cont es o <br /> udx:r of Tanks at facility /I kqe of Tanks(if available) Type of Tank tool i fbrpl hpl Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested? es o " ailed pracicion test 7 ec o If yes, Hive date(c) <br /> as a repair made to the tank system? ec No 11f yes, what was repaired7 <br /> os rcixrir done urnler InspcctionT es o era soil sampler anely:ed7 es o1. ITXE 7f PH G P11 0 'b/EUD <br /> type of failure/discharge atastrophic Long-term lage verfill mown cher: <br /> eak <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ;oil S mples ReceivedesIX epth to Ground Water �� of/Year verage Annual Precipitation <br /> IN. 14 10-25 <br /> Site WCLL(s) es o unbar 1 Type Irr orm ub <br /> S core S core S core <br /> )istance to Wells) from Tank, It; ft; ft C t0 pts C V pts C pts <br /> 0 iT 0 if 0 if <br /> R onditIon R condition R -ordition <br /> Site feature - Leaching Potential Analysis E is nwc E is mrc E is mac <br /> inimasm Depth to groundwater from the Soil Suaple (feet) >100 1-100 15 50L1 <br /> • ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxxx <10 9 10-25 Kxxxxxx 26-4012 <br /> nn-Hade conduits which increase vertical migration <br /> ,l leachate (i.e., septic systaim, water wells, ponds) None Unknown r,, resent e,) <br /> pique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxx None One one <br /> COLUMN TOTALS»>TOTAL POINTS O • �� <br /> ;aiple Result: (B T X ON E) RANGE Of TOTAL POINTS ,9 pts or more 41 - 48 pts 40 pts or less <br /> R T x E B T X E <br /> MAXIHUM ALLOWABLE B-T-X-E LEVELS (PPM) t 50 50 50 <br /> .aiplr Result: •ASULINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 't- '" �'! TPM ^�.^- IESEL 10,000 1lx)0 100 <br /> WINOTES: •••If docuir:nted soil and/or ground water contrrnination is present, do not caiplete the leaching potential <br /> analysis. (i.e., site Is currently on UGT Contisnination List for soil or ground water.) <br /> �Lj If depth is > 5 ft. and < 27 ft., score 0 points. If depth -5 ft., do nut use table. <br /> \ If precipitation is > 40 inches, score 0 points. <br /> L Levels for OTXLE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX L E or TPM Concentrations > Allowable Levels Yes o rq <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Eva anon <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 fES 0 <br /> ATC REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME Of <br /> VALUATOR ( -- <br /> fll 21 80 (UGTWKSHT)\5/90 <br />