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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I • UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE /I t� <br /> AME OF FACILITY e O WEEPS CODE / ! - <br /> ADDRESS / �. Ile 2 S , ANK ID # J��--D <br /> TANK SIZE �O UEL TYPE G�f <br /> 11 , GENERAL SITE HISTORY <br /> Is permit current? es o ermit # acility Status Code oc . Soi L/GW Cont as Fo <br /> umber of Tanks at facility ge of Tanks( if available) ype of Tank teel Fbrgl I ngl I Dual <br /> III . TANK HISTORY <br /> as Tank tested? esa ailed precision test 7 es o If yes , give date( s ) <br /> as a repair made to the tank system? as No f yes , what was repaired? <br /> as repair done under inspection? as 40 ere soil samples analyzed? es o 1 TXE I PH- G I PH -D I b/EDB <br /> Type of failure/discharge atastrophic long- term Leakage verfill nknown cher : <br /> IV . REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS ) <br /> Soil Samples Received as o epth to Ground Water 6 of/Year �G 9� verage Arcual Precipitation 4= 4 0- 25 <br /> n- site WeLL (s ) as o umber & Type I Irr I om I ub <br /> S Score 5 Score S Score <br /> istance to WeLI ( s ) from Tank ft ; ft ; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R canditi on 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 ) �dJ� a > 100 1 - 100 25- 501 <br /> Fractures in subsurface ( applies to foothills or mountain areas ) M None Unknown resent <br /> verage Arcual Precipitation ( inches ) KXXXXX < 10 9 10-25 Kxxxmx 26- 40L <br /> Ian-Made conduits which increase vertical migration / <br /> f leachate ( i . e. , septic systems , water wells , ponds ) ! G None Unknown Dresent <br /> pique site features : Recharge area , coarse soil , nearby wells . At Least 4ore than <br /> xxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS zo + + <br /> Sample Result : IS T X OR E ) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> V �i°�r� <br /> 8 T X E B T X E <br /> F�3 /- 7,��n ✓ MAXIMUM ALLOWABLE B- T -X • E LEVELS (PPM ) 1 50 50 50 . 3 . 3 1 . 1 . NAL <br /> Sample Result : ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS ( PPM ) <br /> J (/ TPH IESEL 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 /> ) 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 /> VI . STAFF RECOMMENDATION/CONCLUSION , <br /> 1 . Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> I2 . Recommend Site Closure as I 0 I I 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 ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EN 23 80 (UGTWKSHT ) \5/90 <br />