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SAN JOAQUIN C NTY:PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEADIVISION <br /> 1• UGST WRKSHEET FOR SITE CLOSURE EVALUATION ATE w 2 '. 3 <br /> AME OF FACILITY C0> EEPS CODE ! p <br /> DDRESS c E <<-��..aK r� S �' TANK ID # <br /> TANK SIZE IFUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # acility Status Code oc of GU Cont es o <br /> umber of Tanks at facility Egeof Tanks(if available) ype of Tank teel Fbrgl ngl ? Dual <br /> iil. TANK HISTORY e <br /> as Tank tested? esI 1I o ailed precision test ? es' o €f yes' givo date(s) <br /> as a repair made to the tank system? Yes No 11f yes, what was repaired? I <br /> ns repair done under inspection? es a ere soil samples analyzed? es, To TXE Pk-G PH-D b/EDD <br /> ype of failure/discharge atastroph-ic long-term teakage verfitt I—Inknown then: "TzP►�- ^4 r 0 <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) SI <br /> Soil Samples Received es o epth to Ground Water of/Year 111&( <br /> �veraqe Annual Precipitation 4 10-25 <br /> Site Wells) IYes oumber & Type trr om ub <br /> S tore S core 5 core <br /> istance to Welt(s) from Tank ft; ft; ft C 10.pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondition <br /> . Site Feature - Leaching Potentiat Analysis. E is met E is met E s'met <br /> inimum Depth to groundwater from the Soil Sample (feet) 3rJ >100 , 1-100 25 50\1 <br /> ractures in subsurface (applies to foothilts or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxxx <10 9 10-25 xXxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration I I <br /> f Leachate (i.e., septic systems, water welts; ponds) None Unknown 3resent <br /> I <br /> mique site features: Recharge area, coarse soil, nearby weils. At least ore than <br /> xxxxx None one one <br /> COLUMN.TOTALS—TOTAL POINTS + 3(, + � <br /> ample Result: (B T X OR E) RANGE OF 101RL POINTS 9 pts or more 4 - 48 pts 40 ptsror-Less <br /> X E E ii T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS;T; <br /> 50 50 .3 .3 1. 1. NA\3 <br /> 'ample Result- ASONE 1000 100 10 <br /> t tp ' �� � LIAXIMUM ALLOWABLE TPH LEVELS, <br /> �i0 �w iMo�a�Nl 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 UOT 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 /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable-Levets Yes o <br /> 2. Recommend Site Ctosure 1Yes +0 1. If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION --TO BE COMPLETED BY A SUPERVISOR! NIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE e.ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> ATT: REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 k h <br /> EH 29 80 F. <br />