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SAN JOAQUIN MS� PUBLIC HEALTH SERVICES/ENVIRONMENTAL HFWt�VISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> OF FACILITY I EPS CODE 2 <br /> RESS rAAK 10 s <br /> AUK SIZE L TYPE � . <br /> 11. GENERAL SITE HISTORY <br /> Vs pes permit currentT es o ermit if - ecitity status Code oe.Soil/GH Cont es o <br /> r of Tanks at facility ' ge of TanksCff available) ype of Tanis teel brgl I ngl I Dual <br /> 111. TANK HISTORY <br /> ns Tank testedT es o ailed precision test T as o If yes, give date(s) <br /> An a repair redo, to the tank system?Ifes No 14f yes, what was repaired? <br /> 'as repair done under inspectionT es oFWOterm <br /> re soil samples 11 analyzedT es o TXE PH-G PN-D /EDB <br /> ype of failure/discharge atostrophie leakage rfIII Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPWTION REPORT FOR SITE OETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> it Samples Received as o epth to Ground Haterof/Year 8,{o verage Arcual Precipitationrt, <br /> 301 <br /> -Site Hells) es r t Type rr omS ore S core S Istance to Hells) from Tuck ft; ft; ft C 0 pts C pts C 0 f 0 if 0 R ondition R ondition R rini� <br /> Feature - leaching Potential Analysis E s met E Is met E <br /> Depth to groundwater from the Solt Sasple <feetT3or—j3 ��— >100 1.100 25-50\1 <br /> s in subsurface (applies to foothitls or moUntsin grass) NonsUnittw+n resent <br /> Amwl Precipitation (Inches) <10 9 10-ZS x 26-40\2 <br /> conduits which increase vertical migration <br /> ate (i.e., septic systems, water wells, ponds) None Unkno n resent <br /> ite features: Recharge area, coarse soft, nearby welts. 9 At team( ore than <br /> None / one one <br /> COLUMN TOTALS>»TOTAL POINTS + 3{p + V <br /> e gqesutt: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B:.iS�pm <br /> T16 D PIP A*61 W09 lakik8 T X E B T IX E <br /> MAXIMI ALLOHABLE B-T-X-E LEVELS tP ) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> to Result: INE 1000 100 10 <br /> lqo hm TPN INUM ALLOUABLE TPH LEVELS CPPN) <br /> �.1y EIESEL 10,000 1000 100 <br /> oOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. Cf.*.. site Is currently on UGT Contamination List for soft or ground water.) <br /> \1 If depth is > 5 ft. ud < 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 (gasolfne) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION Kp� <br /> 1. Are BTX 1L E or TPN Concentrations > Al le Levels es —j -3. "- is ; j• <br /> 2. Recommend Site Closure es If Yes, Refer to Site Mitigation for Evatuatian -T?* 3(60 <br /> VII. REVIEH EVALUATION - TO BE COMPLETED BY A SUPERVISOR MOR <br /> rISANNITN STAFF RECOM E110ATION FOR CLOSURE S EFERRED TO SITE MITIGATION FOR EVALUATION ES <br /> K <br /> EFERRED / �•- / ATE CLOSURE LETTER MAILEO <br /> F <br /> TOR <br /> EN 23 80 (UGTWKSHT)\5/90 <br />