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SAN JOACUIN C(--*"-*PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALVISION <br /> t. UGST WORKSHEET FOR SITE CLOSURE EVALUATION A I E <br /> nME OF FACILITY L � SWEEPS CODE <br /> OORESS / - TANK IO # t 0 1 <br /> [ARK SIZE IFVEL TYPE <br /> 11. GENERAL SITE HISTORY .. <br /> is permit currentl eso ermit # - acility Status Code g-( oe.So /GW Cont es o <br /> unber of Tanks at facility Q ge of Tanks(if available) ype of Tank Leel brgl ngl Dual <br /> III. TANK HISTORY <br /> Jas Tank tested? es o ailed precision test 7 es o If yes, give date(s) <br /> Jos a repair made to the tank system? es No I . f yes, what was repaired? <br /> ns repair done under inspection? es I I go IJere soil samples analyzed? es o TXE PH-G I PH-D WEDS <br /> ype of failure/discharge atastrophic long-term leakage verfill nownI lo they: <br /> TV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water v of/Year $'6 ;� verage Annual Precipitation 4 0-25 <br /> -Site Wells) es o umber S Type lrr — ub <br /> S core S core S core <br /> istance to WeII(s) from Tank ft; ft; ft C 10 pts C pts C pts <br /> O .f 0 if O f <br /> R ronditicri R condition R ondition <br /> Site Feature - Leaching Potential Analysis E f is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet)A ��'.Ct / >100 1-100 O 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> t leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> ique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + ✓� + D <br /> ample Res It: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B � " :dn�p� B T X E 8 T X E <br /> MAXIMLM ALLOWABLE B-T-X-E LEVELS (PPM)1,1, <br /> PPM) 1 50 50 50 .3 .3 i. 1. NA\3 <br /> Sample Result: ASOLINE 1000 100 10 <br /> tel _ AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> / TPH 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 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 BTXSE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation ,r 4,144 <br /> VTI. 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 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED % / <br /> inME OF <br /> :VALUATOR <br /> EN 23 80 (UGTWKSHT)\5/90 <br />