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SAN JOADUIN CCUNFY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL,.. DIVISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> +AME OF FACILITY 4�, ;• `1 EEPS CODE <br /> 1DRESS ANK ID d <br /> AFS' SIZE UEL TYPE <br /> GENERAL SITE HISTORY <br /> s permit current? as ermit 0 acility Status Code oc.Soil/GW Cont es o <br /> •Lrnber of Tanks at facilitoy ge of Tanks(if available) Irype of Tank IS <br /> teel I Fbrgk ryl I Oual <br /> TANK HISTORY <br /> as Tank tested? es IN IF i a ailed precision test ? es o If yes, give date(s) / <br /> ':s a repair made to the tank system? es No 11f yes, what was repaired? <br /> .ns repair done under inspection? es o ere soil samples analyzed? es Fo TXE PH G PH-0 b/EDB <br /> rpe of failure/discharge atastrophic long-term leakage verfill nknown cher: <br /> REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .oil Samples Received es o epth to Ground Vater of/Year verage Annual Precipitation = 4 10-25 <br /> 7n-Site Well(s) es o umber & Type Irr )an uv <br /> S core S Score S Score <br /> istance to Wells) from Tank ft; ft; ft C 0 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ordition <br /> �. Site Feature - Leaching Potential Analysis Es met E is met E is met <br /> +inimtm Depth to groundwater from the Soil Sample (feet) >100 ' �51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) ��-1 None Unknown Present <br /> ivcrage Annual Precipitation (inches) d xxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> 4nn-Made conduits which increase vertical migration <br /> ,f leachate (i.e., septic systems, water wells, ponds) & None Unknown resent <br /> 1.nique site features: Recharge area, coarse soil, nearby wells. ( At least ore than <br /> xxxxx None L/ one one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> ,ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9-pts r more I 41 48 pts 40 pts or less <br /> y ' Z /Zinn S T X E 3 T X <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 150 50 50 .3 .3 1. 1 1. NA\3 <br /> Sample Result: )GASOLINE 1000 I 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IDIESEL 10,000 1000 100 <br /> FCOTNOTES: "'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 STX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> STAFF RECOMMENDATION/CONCLUSION / / <br /> 1, Arc BTX & E or TPN Concentrations > Allowable Levels Yes -7F o <br /> 2. Recomnend Site ClosureIYes o ✓ If Yes, Refer to Site Mitigation for Evaluation <br /> REVIEW EVALUATION - TO BE CC14PLETED BY A SUPERVISOR/SENIOR <br /> .CNCUR WITH STAFF RECCMMEHOATICN FCR CLOSURE ES ) 0 �EFERRED TO SITE MITIGATION FCR EVALUATION ',YES 0 <br /> nATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> f <br /> NAME ^.F <br /> EVALUATOR <br /> :H 23 80 (UGTWKSHT)\5/90 <br /> ^o :n <br />