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SAN JOAQUIN C�uuNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA�LH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY WEEPS CODE 2 C:)� <br /> OORESSg" 1 TANK ID # <br /> TANK SIZE UEL TYPE <br /> f� L �7 �1�DC 1. <br /> I I. GENERAL SITE HI eTORY <br /> Is permit current? es o ermit # lFaciLity Status Code1 16 oc.Soit/GW C Jo <br /> umber of Tanks at facitity { ge of Tanks(if available) lf� ype of Tank IS teel Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? es o ailed precision test ? es INO <br /> If yes, give dates) <br /> Was a repair made to the tank system? es No 11f yes, what was repaired? <br /> Was repair done under inspection? No ere soil samples analyzed? 1Yes Jo TXE I IT <br /> PH-G I IT <br /> PH-0 I 1Pb/EDB <br /> IT ype of failure/discharge atastrophic long-term leakage verfitt I nknown 1 10cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .oil Samples Received es 1401 epth to Ground Water 3 IR of/Year ins; $(o verage Annual Precipitation A= 4 10-25 <br /> Dn-Site well(s) es o I umber & Type Irr on ub <br /> S Score S Score S Score <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) 1 None Unknown Dresent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration �] <br /> Df leachate (i.e., septic systems, water welts, ponds) None —1 Unknown Dresent <br /> Jnique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxxx None one one <br /> COLUMN TOTALS>>TOTAL POINTS <br /> ampte Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br />� 3 E3 - NoQ topQ� <br /> E - 4410 p B T X E B T X E <br /> 25$b ? D LD�,>w+ MAXIMUM ALLOWABLE B T X E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> -ample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PFM) <br /> D D TPH IESEL 10,000 1000 100 <br /> OOTNOTES: ***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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION Np{e<: S-b 416o cc"fac^42 i <br /> upPw, 1,3-516hloe'o120w1LL"Q <br /> 1. Are BTX & E or TPH Concentrations > Allowable LevelsYes Jo <br /> 2. Recommend Site Closure 1Y <br /> es o If Yes, Refer to Site Mitigation for Evaluation ra w <br /> Vil. REVIEW EVALUATION - TO BE COMPLETED GY A SUPERVISOR/SENIOR <br /> -ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE "ES '0 EFERRED TO SITE MITIGATION FOR EVALUATION ES JO <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />