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i - <br /> SAN JOAQUIN COUNif PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH ,VISION <br /> I . UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY WEEPS CODE �0 � <br /> Day pct r; w _ � P <, <br /> (� c ,^UCID ANK ID ft <br /> TANK SIZE 5700 UEL TYPE I ( 1 101 <br /> 11 , GENERAL SITE HISTORY <br /> Is permit current? es a J ermit if - ecility Status Code CM oc . SoiL/GW Cont es o <br /> umber of Tanks at facility 4�z Be of Tanks( if available Fbrgl I l Dual <br /> 111 , TANK HISTORY " k 3 l <br /> NN <br /> Jos Tank tested? as o P.maZ ailed precision test ? as , give date( s ) <br /> as a repair made to the tank system? Yes WDA%' ' J f yes , what was repaired? <br /> as repair done under inspecti on7 es o ere soil samples analyzed? as o TXE PH- G PH-D b/EDB <br /> Type of failure/discharge atestroph is Long- term leakage verfiLL +known cher : <br /> IV . REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS ) <br /> oil Samples Received es Y o epth to Ground Water k • 5 of/Year c ; /iSa verage Annual Precipitation = 4 0 - 25 <br /> - Site NeI L (s ) as o O umber 8 Type Irr om ub <br /> S core S core S 3core <br /> istance to Wells ) from Tank ft ; ft ; ft C 0 pts C pts C pts <br /> O if 0 if O if <br /> R onditi on R ondition R ondition <br /> J . Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Sail Semple ( feet ) > 100 1 - 100 5 25- 5011. <br /> Fractures in subsurface ( applies to foothills or mountain areas ) None Unknown resent <br /> Average Annual Precipitation ( inches ) xxxx c10 9 10- 25 KMXMX 26-40 2 <br /> an-Made conduits which increase vertical migration <br /> I leachate ( i . e . , septic systems , water wells , ponds ) None Unknown S resent <br /> pique site features : Recharge area , coarse soil , nearby wells . At least ore than <br /> xxxx None 9 one �Jone <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> Sample Result : (8 T X OR E ) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> i Q % E B T % <br /> MAXIMUM ALLOWABLE B- T % E <br /> i B T <br /> 9 -E LEVELS ( PPM) 1 50 50 50 .3 .3 1 . 1 . NAL <br /> ample Result : — ASOLINE 1000 100 10 <br /> • PH—D AXIMIM ALLOWABLE TPN LEVELS ( PPM) <br /> �Y'76" QeM TPH IESEL 10 , 000 1000 100 ~ <br /> OOTNOTES : *** If documented soil and/or ground water contamination is present , do not canp fete the leaching pnfent Tal <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 net 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 (diesel ) . <br /> VL STAFF RECOMMENDATION/CONCLUSION <br /> 1 . Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> yn Poe /5 / 2 PF^4 <br /> 2 . Recommend Site Closure as o If Yes , Refer to Site Mitigation for Evaluation Ms vt �o/O <br /> V11 . REVIEW EVALUATION - TO BE CCMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES MO <br /> ATE REFERRED / / J ATE CLOSURE LETTER MAILED <br /> AME OF <br /> -VALUATOR <br /> EH 23 80 (UGTWKSHT )\5/90 <br />