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SAN JOAQUIN`�y{'HTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE� DIVISION <br /> I UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> nME OF FACILITY EEPS CODE <br /> DORESS "22�J /I, >/ ANK ID # <br /> IANK SIZE ��ov UEL TYPE <br /> II. GENERAL SITE HISTORY <br /> fY <br /> Is permit current? es o ermit # - acitity Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) IT <br /> ype of Tank teet brgl ngl Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested7 es 1H. ailed precision test 1 1 Yes o If yes, give date(s) <br /> as a repair made to the tank system? Yes No 11f yes, what was repaired7 <br /> Jas repair done under inspection? es o ere soil samples analyzed? es It <br /> TXE I IT <br /> PH-C PH-D I 1Pb/E08 <br /> ype of failure/discharge atastrophiC tong-term leakage 7erfill I nknown I lother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es IHOI <br /> epth to Ground dater of/Year verage Annual Precipitation N= 4 0-25 <br /> Site Well(s) es o umber b Type Irr om ub <br /> S Score S Score S Score <br /> istance to Wetl(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 `A5 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 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> ique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS AL + /2 + <br /> ample Result: (B T X OR E) 9 RANGE OF TOTAL POINTS pts or more 41 - 48 pts 40 pts or less <br /> 0 5—Ap..--- CS/ B 1 t X E B IT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: GASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> /o M TPH IESEL 10,000 1000 100 <br /> OOTNOTES: 'f*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 /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX $ E or TPN Concentrations > Attowable 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 /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE VES1 0 EFERRED TO SITE MITIGATION FOR EVALUATION E5 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> TAME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />