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SAN JOAQ COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTIATH DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> AME OF FACILITY 1 L/ WEEPS CODE <br /> DDRESS , TANK ID #7 <br /> TANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # acility Status Code oc.Soil/GW Cont es Jo <br /> umber of Tanks at facility ge of Tanks(if available) IType of Tank tee( Fbrgl I IS <br /> ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es I IN01 <br /> ailed precision test ? es o If yes, give dates) / <br /> as a repair made to the tank system? Yes No 11f yes, what was repaired? <br /> �s repair done under inspection? es o ere soil samples analyzed? es Jo TXE PH-G PH-0 b/EDB <br /> 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 /> .o11 Samples Received es o epth to Ground Water l'� of/Year j( verage Annual Precipitation A= 4 10.25 <br /> n-Site Wells) es o Number & Type Irr om ub v <br /> S Score S Score S Score <br /> Distance to WeLI(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 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) >100 1-100 ^ 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown Dresent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 Kxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None 9 Unknown Dresent <br /> lnique site features: Recharge area, coarse soil, nearby wells. At Least 4ore than <br /> xxxx None one one <br /> COLUMN TOTALS»-TOTAL POINTS <br /> 3amp'1le Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or Less <br /> �v L•�` f�'�M X B T XFEBJT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 .3 .3 1. 1. NA\3 <br /> 'ample Result: GASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 1 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 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 Level <br /> sYes L'41 <br /> 0 <br /> 2. Recommend Site Closure es o ✓ If Yes, Refer to Site Mitigation for Evaluation <br /> VTI, REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CNCUR WITH STAFF RECOMMENDATICN FOR CLOSURE •ES '0 EFERRED TO SITE MITIGATION FOR EVALUATION ES JO <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> EH 23 30 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />