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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALir D1 " ISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> WEEPS CODE <br /> AME OF FACILITY <br /> DRESS AN/K ID <br /> TANK SIZE UEL TYPE <br /> 11 . GENERAL SiTE HISTORY <br /> Is permit current7 es o ermit 0 - acility Sxatus Cade oc . Soil/GW Cant es o <br /> umber of Tanks at facility 9 <br /> e of Tenks( if available) ype of Ten tee Fbrgl ngl Dual <br /> III , TANK. HISTORY <br /> as Tank tested? es o ailed precision test 7 es Oil 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? es o ere soil samples analyzed? es o I TXE PH• G PH-D b/EDB <br /> ype of failure/discharge atastrophic Long- term leakage verfill nknown they : <br /> IV . REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS ) <br /> oil Samples Received es o epth to Ground Water 35�,o of/Year S6 ; Qj verage Annual Precipitatio = 0- 25 <br /> n- Site Well es o umber 8 Type Irr om ub <br /> S core S core S core <br /> istance to WeLI ( s ) from Tank ft ; ft ; ft C 0 pts C pts C fPts <br /> 0 if O if 0 <br /> R ondition R ondition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sade ( feet ) <br /> > 100 1 - 100 25 . 50L <br /> ractures in subsurface (applies to foothills or mountain areas ) <br /> None Unknown resent <br /> verage Annual Precipitation ( inches ) xxxx < 10 9 10- 25 xxxxxx 26-40L <br /> an-Made conduits which increase vertical migration O None Unknown resent <br /> f leachate ( i . e . , septic systems , water wells , ponds ) <br /> At least ore than <br /> nique site features : Recharge area , coarse soil , nearby wells. xxxxx None ane one <br /> COLUMN TOTALS»>TOTAL POINTS �O ' Z ~ �Z <br /> ample Result :: (B f�' �RARA PSE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> CD-To-we, 3 <br /> T X E B T % E <br /> '$6 /roy MAXIMUM ALLOWABLE B- T-%-E LEVELS ( PPM ) 1 50 50 50 Y33 1 . 1 . NAL <br /> ASOLINE 1000 <br /> Le Resu 00 10 <br /> isAXIMUM ALLOWABLE TPN LEVELS ( PPM ) 100 <br /> � &'7 (7 TPH IESEL 100000 1000 <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 net use table. <br /> \2 If precipitation is > 40 inches , score 0 points . <br /> L Levels for OTXBE are not applicable at a TPH concentration of 10 ppm ( gasoline) or 100 ppm (diesel ) . <br /> VI , STAFF RECOMMENDATION/CONCLUSION j <br /> 1 . Are BTX 8 E or TPH Concentrations,>ALIo_ wable Levels Yes I o <br /> 2 . Recommend Site Closure es ( o' if Yes , Refer to Site Mitigation for Evaluation <br /> Recommend <br /> VII , REVIEW EVALUATION - TO BE COMPLETE6 BY A SUPERVISOR/SENIOR / <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 E ED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> HREFERREDATE CLOSURE LETTER MNILED <br />�, EH 23 80 (UGTWKSHT ) \5/90 <br />