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SAN JOAOUIL COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE %4_ <br /> AME OF FACILITY % l�tio /S WEEPS CODE <br /> DRESS �r���,; �� �T��/ TANK 1D <br /> TANK SIZE SG CC < UEL TYPE � '' <br /> 11. GENERAL SITE HISTORY <br /> ** <br /> Is permit current? es o ermit # - acility Status Code ID -Soil/GW.Cont es o <br /> umber of Tanks at facility �; ge of Tanks(if available) ype of Tank teel rgL ngl Dual <br /> i% <br /> III. TANK HISTORY <br /> as Tank tested? o es L" aIfiled precision test ? es o yes, give date <br /> as a repair made to the tank system? Yes No v 11f yes, what was repaired? <br /> as repair done under inspection? Ifes No 4ere soil samples analyzed? es r; o TXI IT <br /> PH-D 1Pb/EDB <br /> Type of failure/discharge atastrophic Long-term Leakage verfill nknown they• itcn/e � /moo/{r <���u.✓ <br /> h / �v. v s�s�- <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received 1Yes o epth to Ground Water of/Year verage Annual Precipitation A= 4 0-25 <br /> On-Site WeLL(S) es o umber & Type Irr om ub <br /> S Score S Score S Score <br /> Distance to WeLL(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if O if <br /> R ondition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 51-100 25-5011 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown 3resent <br /> Average Annual Precipitation (inches) xxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown 3resent <br /> pique site features: Recharge area, coarse soil, nearby wells. G} At Least 4ore than <br /> xxxxx None // one one <br /> COLUMN TOTALS»>TOTAL POINTS + 3 v + <br /> ample Re ult: (B T X OR E) RANGE OF TOTAL POINTS9 pts or more 41 48 pts 40 pts or Less <br /> B I T X E 8 JT X E <br /> /? MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAS <br /> Sample Result: GASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH DIESEL 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 /> L If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> 12 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 /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <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 <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fEs 0 EFERRED TO SITE MITIGATION FOR EVALUATION fES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />