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SAN JOADUIN CITY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HES DIVISION <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> nME OF FACILITY 7 y EPS CODE 15--'791 <br /> T`7 <br /> ODRESS , 2/� 'V TANK 1D _! <br /> TANK SIZE S-Uv UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current7 es o ermit 0 - acility Status Code oe.Soit/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank IS <br /> Leel Fbrgl I 1Sngt I Dual <br /> 111. TANK HISTORY <br /> Was Tank tested7 es IHOI ailed precision test 7 es o If yes, give date(s) <br /> as a repair made to the tank system? Yes No f yes, what was repaired? <br /> Jas repair done under inspection7 es o ere soil samples analyzed? es o DB <br /> TXE PH-GT PN-0 b/E <br /> ype of failure/discharge atastrophic tong-term leakage verfill known I lother: <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 hater of/Year verage Annual Precipitation k= 4 0-25 <br /> -Site Wells) es I o I umber b Type I Irr om ub <br /> S core S Score S Score <br /> istance to Well(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R ondition <br /> 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 resent <br /> verage Amual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration q <br /> f leachate (i.e., septic systems, water wells, ponds) None 1 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 /(0 * � + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> T ,UI 3��_ B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: SOLINE 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 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 8TX3E 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 TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es I o If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES 0 EFERRED TO SITE MITIGATION FOR EVALUATION VES 0 <br /> ATE REFERRED 27// ATE CLOSURE LETTER MAILED <br /> In ME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />