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SAN JOAQUI$%)XNTY PUBLIC HEALTH SERVICEi,S/ENVIRONMENTAL IWTH DIVISION <br /> +� 1• UGST WORKSHEET. FOR SITE CLOSURE EVALUATION AYE .(�!,U <br /> AME OF FACILITY "tVWEEPS CODE I Jr 11 <br /> DRESS r)I TANK ID Il - <br /> t <br /> AHK SIZE UEL TYPE <br /> I1. GENERAL SITE HISTORY <br /> wr <br /> Is permit current? eso ermit q - ! acility Status Code oc.Soit/GW Cont k,, o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank teel Fbrgl ngl Dual <br /> I11. TANK HISTORY <br /> Jas Tank tested? o ailed precision test. ? es o If yes, give dates) <br /> _F <br /> Jas a repair made to the tank system? as No f yes, what was repaired? <br /> as repair done under inspection? es ere soil saapies analyzed? as a <br /> o TXE PH-G PH-D b/EDB <br /> Lyof failure/discharge atastrophic Lang-term leakage verfill sown ther: <br /> L <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 of/Year verage Annual Precipitation 4 0-25 <br /> an <br /> -Site Wells) es o umber $ Type 1rr am ub <br /> S Score 5 Score Score <br /> istance to Wells) from Tank ft; _f t; Oft C 10. pts C 9 pts G i pts <br /> 0 if 0 if 0 if <br /> R <br /> condition R condition R ondition <br /> W. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-501 <br /> Fractures in subsurface (applies to foothills or mountain areas) ;, None Unknown PIresent <br /> verage Annuat Precipitation (inches) ` i xxxxx 00 9 10-25 xxxxxxx 26-40 f <br /> s <br /> Ian-Made conduits which increase vertical migration a Vo <br /> f leachate (i.e., septic systems, water we(ls, mss) None Unknown ! resent <br /> niolue site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxx None one / one <br /> f A <br /> COLUMN TOTALS»>TOTAL POINTS + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL-POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> 31 <br /> ` a T x E e JT x E <br /> 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 /> IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ""If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently ori UGT Contamination List for sail or ground water.) <br /> ,L If depth is > 5 ft. and < 25 ft., score 0 points. if-depth r_5 ft., do not use table. <br /> ,L2 If precipitation is > 40 inches, score 0 points: <br /> i Levels for BTX&E are not applicabte 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 > Allowabte Levets Yes o <br /> 2. Recommend Site C�reo If Yes, Refer to Site Mitigation for Evaluation <br /> VI1. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE tH 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> 'VALUATOR k <br /> EH 23 80 (UGTWKSHT)\5/90 <br />