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SAN JOAQUIN WTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEQ. DIVISION F <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATIONATE <br /> qAME OF FACILITY ��/I EPS CODE U <br /> DDRESS �� ANK ID # <br /> TANK SIZE 1 D,006 UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? as a ermit >e acility Status Code oc.5�o1''�GW Cont es o <br /> umber of Tanks at facility ge'of Tanks(if available) ype of Tank teal X Fbrgl ngl Dual <br /> Ill. TANK HISTORY <br /> 'as Tank tested? es o ailed precision test ? es a If yes, give date s) <br /> as a repair made to the tank system? Yes No 1Y 11f yes, what was repaired? E <br /> as repair done under inspection? es o ere soil samples analyzed? 1Yas I �( Io I TXE 0PH-G �- PH-D II_ EDD 1 , <br /> ype of failure/discharge atastrophic long-term leakage verfil nknown I lother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es IX o epth to Ground Water Sv of/Year (p verage Annual Precipitation _ 25 <br /> -Site Wells) IYes 1 110 umber & Type 11r om ub i <br /> S Score S Score 5 3core <br /> istance to WeLL(s) from Tank ft; ft; ft C 0:pts C 9 pts C 5 pts <br /> 0 if. 0 if 0 •ft <br /> V. ondition R condition R ondition <br /> Site feature - Leaching Potential AnalysisR' E is met E is met E 'simet <br /> inimum Depth to groundwater from the Soil Sample (feet)50-• :z: 33 >100 1-100 25.50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) M None Unknown Present <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 25-40\2 <br /> an-Made conduits which increase vertical migration 0f leachate (i.e., septic systems, water wells; ponds) None Unknown resent a <br /> l <br /> lnique site features: Recharge area, coarse coif, nearby wells: At least 4ore than <br /> xxxxx None one ! one <br /> 1�} <br /> COLUMN TOTALS»>TOTAL POINTS !V + 2 + <br /> k <br /> ample Result: (B T X OR E) RANGE OF TOTALPOINTS 9 pts or more 41 - 48 pts 40 pts.'or less <br /> nj B i X . E B T X E f� <br /> MAXIMUM ALLOWABLE D-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: ASOLINE 1000 i00 10.E <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 0 <br /> 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 BTX&E are not applicable at a TPH concentration of- 10 ppm (gasoline) or 100 ppm (dies,l). <br /> V1. STAFF RECOMMENDATION/CONCLUSION h <br /> t. Are BTX & E or TPH Concentrations > Allowable Levels Yes e <br /> 2. Recommend Site Closure es If Yes, Refer to Site Mitigation for Evaluat <br /> oion # <br /> i <br /> VII. REVIEW EVALUATION - TO BE C011PLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE 'E5 0 EF ERRED TO SITE MITIGATION FOR EVALUATION ES 40 !� I <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> -VALUATOR <br /> i! <br /> EN 23 80 (UGTWKSHT)\5/90 1i <br /> EH 29 80 <br />