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SAN JOAQIIifCOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTALSIALTH DIVISION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION )ATEJ/ 5 <br /> OF FACILITY SWEEPS CODE <br /> DRESS o� TANK 10 It - -' t! <br /> ANK SIZE 0 D UEL TYPE Q <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o it # - aciIIty Status Code oc.Soil/GW Cont as o <br /> *Amber of Tanks at facility go of Tanks(if available) ype'of Tank tool br91 t Dual <br /> Ill. TANK HISTORY <br /> Jas Tank tesit ss o I VIalted precision test t es 0 if yes, give date(s) <br /> Jaz a repair made to the tank system? es No f yes, what was repaired? <br /> s repair done under inspection? es o re soil samples analyzed? as TXE PH-G PH-0 EDB <br /> ype of failure/discharge Datastrophic tarp-term leakage fill they: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> it Samples Received es o I epth to Ground Water 14D of/Year 216 ; verage Annual Precipitation ■ 4 0-25 <br /> -Site Wetl(s) as o �umber i Type Irr am <br /> S Score S Score S core <br /> istance to Welts) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R ondition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E s met E is met E s met <br /> inimum Depth to groundwater from the Solt Sample (feet) (w l5_ >100 1-100 25-50L <br /> ractures in subsurface (applies to foothills or mountain areas) O None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX 410 9 10-25 Kxxxxxx 26-4012 <br /> 4an-kade conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown Present <br /> ique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxxxx None one one <br /> COLUMN TOTALS>»TOTAL POINTS f 7 ♦ � <br /> ample Result OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> - I q <br /> 8 T X E B IT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA13 <br /> ample Result: INE 1000 100 10 <br /> 119M ALLOWABLE TPN 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 an UGT Contamination List for soil or ground water.) <br /> 1l If depth is > 5 ft. and < 25 ft., score 0 points. If depth -5 ft., do not use table. <br /> 12 If precipitation is > 40 inches, score 0 points. <br /> _' Levels for BTXLE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMilEN0ATI0N/CONCWSION ��S eC`�8 v Kr �, w W dzz;7 <br /> / <br /> 1. Are BTX i E or TPH Concentrations > Attowable Levels Yes o <br /> 2. Recommend Site Closure es If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> WITH STAFF RECOMMENDATION FOR CLOSURE ES EFERRED TO SITE MITIGATION FOR EVALUATION VES <br /> AT£ REFERRED C�L— / ?, / ATE CLOSURE LETTER MAILED <br /> INC OF <br /> VALUATOR �— <br /> EM 23 80 (UGTWKSHT)\5/ <br />