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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY LAJ 00SWEEPS CODE <br /> ADDRESS l �/ TANK ID # <br /> TANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> ** <br /> Is permit current? es o ermit # - acility Status Code ID <br /> oc.Soil/GW Cont 1Yes o <br /> umber of Tanks at facility ge of Tanks(if available) IT <br /> ype of Tank IS <br /> tee? Fbrgl I Isngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o a1 IF iled precision test 1 es o If yes, give date(s) / <br /> as a repair made to the tank system? Yes No 11f yes, what was repaired? <br /> as repair done under inspection? esere soil samples analyzed? es o TXE PH-G PH-D <br /> o b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verfill nknown 1 10ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Ifes o epth to Ground Water of/Year verage Annual Precipitation = G 0-25 <br /> n-Site Wells) es o umber & Type Irr om ub <br /> S Score S Score S Score <br /> istance to We(L(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 LJ] 25-501 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown - - resent <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-4012 <br /> an-Made conduits which increase vertical migration — <br /> f leachate (i.e., septic systems, water wells, ponds) None '�' Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxxx None I one L one <br /> COLUMN TOTALS»>TOTAL POINTS ��i� + j` .� + <br /> Sample Result: (B llTX OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or Less <br /> �aoci <br /> v <br /> 1 B T X E BJTX EMAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 . 1. 1. NA13 <br /> Sample Result: ASOLINE 1000 100 10 <br /> q •.(1 AXIMUM 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 on UGT Contamination List for soil or ground water.) <br /> L If depth is > 5 ft. and < 25 ft., score 0 points. If depth <-5 ft., do not use table. <br /> L If precipitation is > 40 inches, score 0 points. <br /> L 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 LevelsYes o <br /> 2. Recommend Site Closure es' o if Yes, Refer to Site Mit gation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES I INO <br /> EFERRED TO SITE MITIGATION FOR EVALUATION YES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />