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,A .. <br /> SAN JOAQUIN NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL It, H DIVISION <br /> 1 . UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY �nwf Pn ECORO ID i 3 E J / <br /> ODRESSa ANK ID # - ,;?A 5 y O <br /> TANK S12E cs.� O UEL TYPE <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 �j ge of Tank ( if available) ype of Tank tee ( Fbrgl ngL Dual <br /> 111 . TANK HISTORY <br /> as Tank tested7 es Nol ailed precision test 7 es o MIf yes , give date( s ) <br /> as a repair made to the tank system? as No t yes , what was repaired7 <br /> as repair done under inspecti m7 es 40 ere soil samples analyzed 7 es o TXE PH- G PH -D b/EDB <br /> Type of failure/discharge atastrophic Lang- term leakage verfill nknown then: <br /> IV . REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS ) <br /> oil Samples Received es I o epth to Ground Water I of/Year verage Annual Precipitation = 4 0- 25 <br /> n- Site Wells ) as o umber & Type Irr W 11 ub <br /> S core S core S core <br /> istance to Wells ) from Tank ft ; ft; ft C 0 pts C pts C pts <br /> 0 if 0 if 0 ' f <br /> R ondition R Dndition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E ' s met <br /> inimum Depth to groundwater frac the Soil Sample ( feet ) > 100 1 - 100 ® 25 - 501 <br /> ractures in subsurface ( applies to foothills or mountain areas ) None Unknown Present <br /> verage Annual Precipitation ( inches ) KXXMX < 10 9 10- 25 xxxxxxx 26- 40L <br /> n- Made conduits which increase vertical migration I <br /> f leachate ( i . e . , septic systems , water wells , ponds ) / 0 None Unknown resent <br /> nique site features : Recharge area , coarse soil , or wells - At Least ore than <br /> (Muncipa L =>2000 ft ; domestic=>500 ft ; irr/agricultural=presenq xxxx None one one <br /> q , <br /> �' '�K„a— COLUMN TOTALS»>TOTAL POINTS � <br /> ample Result : ( e T X OR E ) Ci ?n RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> '-a a = � 1vPYVL� X = <br /> –r� � � � PrI yyY 8 T X E B T X E <br /> MAXIMUM ALLOWABLE B - T- X-E LEVELS ( PPM ) 1 50 50 50 .3 . 3 1 . 1 NA <br /> ample Result : ASOLINE 1000 100 10 <br /> Lr 7D0,0pp ii(� 'PH Q AXIMUM ALLOWABLE TPH LEVELS ( PPM ) IESEL 10 , 000 1000 100 <br /> OOTNOTES : "* If documented soil and/or ground water contamination is present , do not complete the leac7(dieset ) , <br /> ial <br /> analysis - ( i . e- , site is currently on UGT Contamination List for soil or ground wa <br /> \ 1 If depth is > 5 ft , and < 25 ft . , score 0 points. If depth <=5 ft . , do not use table- <br /> t If precipitation is > 40 inches , score 0 points - <br /> Levels for BTX&E are not applicable at a TPH concentration of 10 ppm ( gasoline) or 100 ppmVI . STAFF RECOMMENDATION/CONCLUSION I41P) �y� � U ,,"pJyy/ Mo <br /> 1 . Are BTX & E or TPN Concentrations > Attowable Levels Yes o ��LGlX.l� iW✓'��✓('Q/�P�e,�7y¢''�i_0 <br /> 2 . Recommend Site Closure es o If Yes , Refer to Site Mitigation for Evaluation N•I <br /> VII . REVIEW EVALUATION - TO SE COMPLETED BY A SUPERVISO LEAD SENIOR <br /> i <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE E 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> ATE REFERRED / 1, / C� \ ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR � <br /> EH 23 80 (UGTWKSHT ) \5/94 <br />