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SAN JOAQUIN �TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HES DIVISION <br /> i <br /> 1' UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> ALE OF FACILITY SAhTG � n _ �j, �Q EEPS CODE <br /> DDRESS �/ IciJG)'hr! Dr ST .�i/u•' AHK ID v <br /> 3 fa7� <br /> AHK SIZE UEL TYPE <br /> 11. GENERAL SITE H1 TORY <br /> Is permit current? as o ermit # acitity Status Code oc (g /GW Cont IYes.', o <br /> umber of Tanks at facility kge :of Tanks(if available) ype of Tankfeet Fbrgl ngl I Dual <br /> Elf. TANK HISTORY y <br /> 'as Tank tested? as o aited precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? 1Yas ND 11f yes, Khat was repaired? �� r <br /> ,:ns repair done under inspection? es o ere soil samples analyzed? es !o TXE PH-G U� PH-D D r .� <br /> YRe of failure/discharge atastrophic long-term leakage verfill nknown ther: ! <br /> Iv. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) F <br /> Soil Samples Received as o epth to Ground Water 50 of/Year ��j verage Annual Precipitation k= 4 10-25 <br /> Site We(((s) Les I o I umber & Type Irr om ub <br /> S Score S Score S ;core <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C i pts <br /> 0 if 0 if 0 fel <br /> R ondition R condition R rondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E 's met <br /> inimum Depth to groundwater from the Soil Sample (feet) SU' {:L/ >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) U None Unknown resent i <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 25'-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, .ponds) None Unknown resent <br /> .4, <br /> mique site features: Recharge area, coarse soil, nearby welts. At least 40re than <br /> xxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS Q + S <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more �- 48.pa 40 pts or Less <br /> I� 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 /> -ample Result: ASOLINE 1000 10 10.E <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> ___O _- TPH IE SEL. 10,000 1000 100r <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.) H <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <:5 ft., do not use table. E <br /> \2 If precipitation is > 40 inches, score 0 points. 4 <br /> \3 Levels for BTX&E are not applicable at a TAH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION ;S <br /> i <br /> i <br /> 1• Are BTX & E or TPH Concentrations > Altowable Levels Yes o <br /> 2. Recommend Site Closure 1Yas o If Yes, Refer to Site Mitigation for Evaluation <br /> '1 <br /> Vii. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 40 �. <br /> ATE REFERRED / ! ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> i <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> Ex 29 80 <br />