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SAN JOAXIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY <br /> , � � 4� � WEEPS CODE 0 <br /> s r� <br /> DRESS �"k � � ? � i �, �.— �� ANK ID # 3 <br /> ANK SIZE ��C'% UEL TYPE� <br /> 11. GENERAL SITE HISTORY <br /> xx <br /> Is permit current? es o ermit # - acility Status Code 0 oc.Soil/GW Cont es o <br /> umber of Tanks at facility kge of Tanks(if available) ype of Tank teal Fbrgl Isngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es 1g. <br /> ailed precision test 7 iYes I 1g. <br /> If yes, give date(s) <br /> as a repair made to the tank system? 1Yes No 1 11f yes, what was repaired? <br /> as repair done under inspection? es I go ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term Leakage verfill I nknown I Jt <br /> her: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received 1Y <br /> es I Igo <br /> epth to Ground Water of/Year Ikverage Annual Precipitation <br /> 3n-Site WeLL(S) es o ii umber & Type frr om ub <br /> S Score S Score S Score <br /> istance to WeLL(S) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if O if 0 If <br /> R ondition R condition R ondition <br /> 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 1-100 25 50,1 <br /> Fractures in subsurface (applies to foothills or mountain areas) j_' None Unknown 3resent <br /> Average Annual Precipitation (inches) XXXAXX <10 9 10-25 xxxxxxx 26-40L <br /> an-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) None �' Unknown Present <br /> pique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxx None '! one one <br /> COLUMN TOTALS»>TOTAL POINTS 1, + T 1 + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> B I T X E BT I X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL3 <br /> Sample Result: d / SOLINE 1000 100 10 <br /> �rTPC ` AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 'i 3A2,01 <br /> IESEL 1 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 /> if precipitation is > 40 inches, score 0 points. <br /> L Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION �`n ��/2 �L- � jG,24 <br /> ��"�(yC7(7 JoeSliw ��, +1Sl�C <br /> 1. Are BTX & E or TPH Concentrations > Allow le Levels Yes o S, 0 <br /> 2. Recommend Site Closure 1Yes o ei If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES I IgO <br /> EFERRED TO SITE MITIGATION FOR EVALUATION YES 0 <br /> ATE REFERRED ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />