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{ .y <br /> r <br /> SAN JOAQUIN 14TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE -.i DIVISION <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE f- 2-19 <br /> ANE OF FACILITY ISWEEPS GODE t . <br /> DDRESSlP O ANK ID <br /> TANK SIZE UEL TYPE <br /> it. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # acility Status Code oc.Solt/GW Cont es 10 <br /> umber of Tanks at facility Ltleof Tanks(if available) IType of Tan4 tee'l I [Fbrgt I 15n9l Rual <br /> Ill. TANK HISTORY <br /> Was Tank tested? es o ailed precision test ? es o If yes, give dates) / <br /> Jas a repair made to the tank System? Yes No 11f yes, what .was repaired? <br /> ns repair done under inspection? es o ere sail samples analyzed? 1Yes Io TXEI I ITPH-G PH-D b/EDB. <br /> ype of failure/discharge atastrophic , long-term leakage verfitt nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground hater' of/Year verage.Annuat Precipitation 4 10.25 <br /> )n-Site Weli(s) es o umber & Type Irr an I ub <br /> S Score S Score 5 Score <br /> istance to wetl(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 Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 J- 25-50\1 <br /> ractures in subsurface (applies to foothitts or mountain areas) I None Unknown resent 1 <br /> verage Annual Precipitation (inches) I xxxxx c10 9 10-25 Kxxxxx,x 26-40\2 <br /> nn•Made conduits which increase vertical migration - <br /> Df leachate (i.e., septic systems, water wells, ponds) None q ,Unknown. resent <br /> lnique site features: Recharge area, coarse soil, nearby wells: At Least lore than <br /> xxxxx None one one <br /> COLUMN TOTALS»>TOTAL,'POINTS L D + + `t", <br /> Sample Result: B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40,pts or less <br /> 13n3P �o .p lS��m <br /> IT ,OoLi B T X E 8 JT JXE <br /> 003 MAXIMUM ALLOWABLE R-T-X-E-.LEVELS (PPM) 1 50 50 50 .3 .3 1: 1. NA\3 <br /> "ample Result: ASOLINE 1000 100 10 <br /> I- p r1 AXIMUM ALLOWABLE TPN LEVELS,(PPM) <br /> I( rTPH-' IESEL. 10,000 1000 100 <br /> QOTNOTE$: ***If documented soil and/or ground water contamination is .present, da not complete the teaching potential <br /> analysis. (i.e.,'jsite is currently on UGT -ContaminationList for soil or ground water:) <br /> \1 If depth is > 5 ft. and.i< 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 STX&E.are-not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel):. <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> i, Are BTX & E or TPH Concentrations > Attowabte Levels Yee. INOEa <br /> "r <br /> 2. Recommend site Closure es o If Yes, Refer to Site Mitigation for Evaluation / (/ <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A'SUPERVISOR/SENIOR r <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE 'ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION. ES TO <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />