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SAN JOAOUIN'%UNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL Hb,WAH DIVISION1. ATE 3 <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> AME OF FACILITY *' WEEPS LOGE <br /> ODRESS 'Z 0 0 MQ!Y\— S1 ANK ID # <br /> ANK Sf2E ?5D UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> is permit current? es o ermit # acility Status Code Co.Soi l/GW Cont es 40 <br /> umber of Tanks at facility Be of Tanks(if available) ype of Tank teel Fbrgl ngl Dual <br /> Ill. TANK HISTORY <br /> 'as Tank tested? es IF <br /> ailed precision test ? es o If yes, give date(s) <br /> is a repair made to the tank system? es No f yes, what was repaired? <br /> ns repair done urder inspection? es 0 ere soil samples analyzed? es to TXE PH-G PH- <br /> Type of failure/discharge atastrophic long-term leakage verfill mknown ther: <br /> IV, REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water 44 of/Year verage Annual Precipitation = 4 10-25 <br /> n-Site Wells) es o umber & Type Irr om I ub <br /> S core 5 core S 3core <br /> Distance to Well(S) from Tank ft; ft; ft C 0 pts C pts C 5 pts <br /> 0 1f 0 1f 0 if <br /> R ondition R onditi on R ondition <br /> v. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) 3f �.._- >100 r 1-100 �J- 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) ' None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <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) GU None Unknown resent <br /> )nique site features: Recharge area, coarse soil, nearby wells. At least �� 1ore than <br /> xXXXX None —( one one <br /> / <br /> COLUMN TOTALS>>>TOTAL POINTS ` v rq <br /> 'ample Result: (0 7 % OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> YRea — <br /> t l• G T x E 8 MAXT x E <br /> X. 11.07 [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 /> q, A%IMUM ALLOWABLE TPM LEVELS (PPM) <br /> I _P� Nk{rit TPH IESEL 1 10,000 1000 100 <br /> OOTNOTES: ---if documented soil and/or ground water contamination is present, do n6t 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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1, Are BTX & E or TPH Concentrations > Allowable Levels Yes to <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> vll. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> .ONLUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 I EFERRED TO SITE MITIGATION FOR EVALUATION ES 10 <br /> )ATE REFERRED F <br /> ATE CLOSURE LETTER MAILED <br /> AME OF <br /> -VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> Ex 29 80 <br />