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SAN JOAQUIN ATY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA DIVISION <br /> !. UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE I/ C <br /> AME OF FACILITY I / / -/V <br /> P L v� ECORD ID <br /> DDRESS I T i / ANK ID I - <br /> aNK SIZE I UEL TYPE <br /> 11. GE14ERAL SITE HISTORY <br /> Is permit current? es o ermit : - acility Status Code oc.SoiL/GW Cont es o <br /> uvnoer of Tanks at facility) pge of Tank(if available) IType of Tank 6eel I r'brgl �Sngl Dual <br /> !!I. TANK HISTORY <br /> i <br /> �as Tank tested? es o ailed precision test ? I es I No If yes, give date(s) <br /> Pas a repair made to the tank system? IYes I No f yes, what was repaired? <br /> as repair done under inspection? It es �lol Jere soil samples analyzed? I'YesI �o I TXE I � PH-GI PH-D I pb/EDB <br /> ype of failure/discharge atastrophic I long-term leakage ) verfill noun ) ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Receivedfes �/�Jo depth to Ground Water �tef/Year (� verage Annual Precipitation �+= l4 0-25 <br /> YL/2 <br /> Dn-Site Well(s) 1Yes �!o dumber & Type 1rr Dcm pub <br /> I I S care S Score S core <br /> I to WeLL(S) from Tank ft; ft; ft C 10 pts C pts C pts <br /> 0 0 if 0 if <br /> R ondition R (Condition R onciition <br /> ". Site Feature Leaching Potential Analysis E s met is met "c rs met <br /> Minimum Depth to groundwater from the Soil Sample (feet), I >100 1-100 I 25-5 <br /> i <br /> Fractures in subsurface (applies to foothiLLs or mountain areas) I e I Unkno present <br /> average Annual Precipitation (inches) x 0 I �_Xxxx 125-40\2 <br /> i <br /> Man-Made conduits which increaseical <br /> bf leachate (i.e., septi s wale w ll ) / Unknown I present <br /> nicue site features: age bred, c or At least ore than <br /> (Munc i pa l=>2000 ft; do t!i- <br /> » ura l s t) xxxx ( None I one I one <br /> COLUMN TOTALS>>TOTAL POINTS <br /> r <br /> ample Result: (B T X OR c") RANGE OF TOTAL POINTS 9 pts or more I 41 - 48 pts I 40 pts or Less <br /> TI T X B X c-d(��- x''��`� MAXIMl1M ALLOWABLE B-T-X-c" LEVELS (PPM50 50 50 .3 1.7 <br /> 3 1. 1. NA\3 <br /> ampie Result: SOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> COTNOTES: *''If documented soil and/or ground water contamination is present, do not cmplete the Leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> Z If depth is > 5 ft, and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> L If precipitation is > 40 inches, score 0 points. <br /> Levels for BTX&E are not applicable at a TPH concentration of 10 Ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION Pb—�"�v <br /> 1. Are BTX & "c or TPH Concentrations > Allowable Levels ( Yes K <br /> o 171- <br /> ( / <br /> SII cl UI� <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for EvaLuation <br /> Q � <br /> 9-lk, <br /> V1!. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE IlES 0 EFERRED TO SITE MITIGATION FOR EVALUATION IES �O I i <br /> ATE REFERRED I / / BATE CLOSURE LETTER MAILED <br /> i <br /> 'AME OF <br /> VALUATOR <br /> E9 23 30 (UGTWKSHT)\5/94 <br />