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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL fIMTH DIVISION <br /> I' UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> �1 <br /> AME OF FACILITY EEPS CODE <br /> ODRESS rNK [D #! <br /> ANK SIZE UEL TYPE <br /> II. GENERAL SITE HISTORY <br /> a* <br /> 1s permit current? es 0 ermit # acility Status Code oc.5oil/GW Cont es ao <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank Leel Fbrgl ngl Dual <br /> 111. TANK HISTORY , <br /> as Tank tested? es o ailed precision test 7 es o If yes, give date(S)F/ <br /> Jas a repair made to the :tank system? es No f yes, what was repaired? <br /> ns repair done under inspection? es o ere soil samples analyzed? es Io TXE PH G PH-D b/EDB <br /> ype of failure/dischargek atastrophic Long-term leakage verfill nknown ther: <br /> 1V. REMOVAL HISTORY (ATTACHO NSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soft Samples Received esi o epth to Ground Water of/Year verage Annual Precipitation = 4 10-25 <br /> Site ucll(s) es o umber & Type Irr am ub <br /> S Score 5 Score 5 core <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> h 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 groundwaier from the Soil Sample (feet) �',Z >100 1-100 25.50\1 <br /> rectures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitatirt on (inches) KXXXXX <10 9 10.25 Kxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) J0 None Unknown Dresent <br /> Inique site features: ReFcharge area, coarse soil, nearby wells: At least ore than <br /> xxxxx None 9 one one <br /> COLUMN TOTALS»>TOTAL POINTS ZO + 1E + <br /> ample Result: (B T X OR E} RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> B 7 X E B ` T X E <br /> i� 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.(PPM) <br /> TPH I 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,Mfor BTX&E are-not applicable at a TPH concentration of 10 ppm (gasoline) or 100 pprn (diesel). <br /> Vi. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > ALlowable-LeveLr, Yes o <br /> ,F <br /> 2. Recommend Site CLosur!e e$ o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> F <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ESEFERRED TO SITE MITIGATION FOR EVALUATION ES <br /> 0 JO i <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VALUATOR i - <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />