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C N t Plld EN <br /> SAN JOAOUI;T ,' NTY LIC HEALTH SE VICES/ENVIRONMENTAL H LTH DIVISION ATE <br /> 1 UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> AME OF FACILITY L- /;:+� WEEPS CODE <br /> DDRESS 12-( S I C '` ANK ID # <br /> TANK SI2E I ` C G 0 IFUEL TYPE 50'l A <br /> 11. GENERAL SITE HISTORY <br /> .s permit current? ks o ermit # acility Status Code oc.Soil/GW Cont es o <br /> um'xr of Tanks at facility ge of Tanks(if available) ype of Tank !eel Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> -as Tank teso <br /> ted? es ailed precision test ? as o If yes, <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> ns repair done under inspection? es qo ere soil samples analyzed? es to TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfiII nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ,oil Samples Received es IN. epth to Ground Water ,520 of/Year I/aPk vera9e Annual Precipitation N= 11 <br /> 4 10-25 <br /> n-Site Well(s) as o 14umber 8 Type Irr c- ub <br /> S Score 5 Score S Score <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R onditiol R condition R onditi on <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 /> Fractures in subsurface (applies to foothills or mountain areas) f/ None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 Kxxxxxx 26-40\2 <br /> nn-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic syst ons, water wells, ponds) None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. �n-7 At least lore than <br /> x/xxxx None '/ one one <br /> COLUMN TOTALS>>>TOTAL POINTS * ( ' <br /> ,ample Result: (B T x OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> W� f�P�m K 12�1'pr� G T % E B T X E <br /> y,5 6 ^rr1 'r MAXIMUM ALLOWABLE B-T-%-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> -ample Result: ASOLINE 1000 100 10 <br /> / �",\ A%IMUM ALLOWABLE TPH LEVELS (PPM) <br /> -76 TPH-\ IESEL 10,000 1000 100 <br /> OOTNOTES: ***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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Arc BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure 1Y <br /> es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE 'ES 0 EF ERRED TO SITE MITIGATION FOR EVALUATION ES 10 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />