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SAN JOAOUIN CCIZr TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL�DIVISION <br /> T. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE (�( <br /> AME OF FACILITY �f� &2,0s WEEPS CODE 3 / <br /> DDRESS l4 ANK ID # - <br /> TANK SIZE Jul q_XJUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? eso ermit # - acility Status Code oc.So i l/GW Cont es o <br /> unber of Tanks at facility Be of Tanks(if available) ype of Tank Leel Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es Ifo <br /> If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> ms repair time under inspection? Ifes o ere soil samples analyzed? es o I T%E I PH-G PH-D I b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verfill nknown I lo <br /> ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Solt Samples Received ITes I 1H. <br /> epth to Ground Water of/Year verage Annual Precipitation = 4 0-25 <br /> >i-Site WeII(s) es o umber 8 Type Irr an ub <br /> 5 3core S Score S 3core <br /> istance to Welt(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ordi tion <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> ini mum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) r0 More Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <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 "I Unknown >resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxx None 9 one one <br /> COLUMN TOTALS>>>TOTAL POINTS + Z- r -7AL7— <br /> ample Result: (e T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> T —.01140 = A/l� B T X E 8 T % E <br /> � —0 38' 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 /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTES: ...If documented soil and/or ground water cont amines tion 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 /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX $ E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> -ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES I VN <br /> EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED F <br /> ATE CLOSURE LETTER MAILED <br /> TAME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />