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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I . UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY <br /> ZA <br /> WEEPS CODE �� ! <br /> DRESS / N O d AN) <br /> TANK SIZE �OdD UEL TYPE G S ✓ <br /> 11 , GENERAL SITE HISTORY <br /> Is permit current? eso ermit # - acility Status Code oc . Soil /GW Cont as o <br /> umber of Tanks at facility Be of Tanks( if available ) ype of Tank tee ( I Fbrgl I ngl Dual <br /> III , TANK HISTORY <br /> t <br /> i <br /> Was Tank tested? as o ailed precision test ? as 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? q0 ere soil samples analyzed? as 1 o TXE I PH - G I PH -D b/EDB <br /> Type of fai Lure/discharge atastrophic long- term leakage verfiLL nknown ther: <br /> IV . REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS ) <br /> I /�/- <br /> j oil Samples Received as o epth to Ground Water 3d A of/Year b V 3 verage Annual Precipitation = 4 0 - 25 <br /> n- Site WeIL ( s ) as o umber 8 Type Irr em ub <br /> S Score S Score S 3core <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 condition R 7ondition <br /> V . Site Feature - Leaching Potential Am Lysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample ( feet � (1a ��� > 100 1 - 100 ',t7; _ 25 - 5011. <br /> Fractures in subsurface ( applies to foothills or mountain areas ) /Q None Unknown Dresent <br /> verage Annual Precipitation ( inches ) KXXXXX < 10 9 10 - 25 xxxxxxx 26- 402 <br /> an -Made conduits which increase vertical migration <br /> f Leachate ( i . e. , septic systems , water wells, ponds ) ljU None Unknown 3resent <br /> pique site features : Recharge area , coarse soil , nearby wells . At least 4ore than <br /> xxmx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS Z // + 49 + 3 � <br /> ample <br /> /Result ; IS T X OR E ) RANGE OF TOTALPOINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> BT % E B T X E <br /> MAXIMUM ALLOWABLE B- T - X - E LEVELS ( PPM ) 1 50 50 50 . 3 . 3 1 . 1 . NA13 <br /> ample Result : ASOLINE 1000 100 10 <br /> � AXIMUM ALLOWABLE TPH LEVELS (PPM ) <br /> OVA 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 /> .\1 If depth is > 5 ft . and < 25 ft . , score 0 points . If depth <=5 ft . , do not use table. <br /> L If precipitation is > 40 inches , score 0 points . <br /> \3 Levels for BTXSE are not applicable at a TPH concentration of 10 ppm ( gasoline) or 100 ppm (diesel ) . <br /> VI . STAFF RECOMMENDATION/CONCLUSION <br /> 1 , Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> 2 . Recommend Site Closure Yes I p0 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 /> EH 23 80 (UGTWKSHT ) \5/90 <br />