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SAN JOAQUIN NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H H DIVISION <br /> I . UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY ECORD ID 3 <br /> DDRESS a S ANK ID # - 5 z _ <br /> TANK SIZE UEL TYPE � i` y, t ;- „_, „ /_ <br /> II . GENERAL SITE HISTORY 4`Z " G��/_/\ L <br /> Is permit current? es x c ermit # - c acility Status Code �. oc . Soit/GW Cont es o <br /> umber of Tanks at facility ] ge of Tank( if available ) ype of Tank test Fbrgl ngl Dual <br /> III , TANK HISTORY <br /> r <br /> Munderinspecti �7TeSF <br /> o ailed precision test 7 es o If yes , givedate( s )tank system? es No f yes , what was repaired? <br /> pection? es o ere soil samples analyzed? es o TXE PH- G PH-D b/EDB <br /> atastrophie Long - term Leakage verfill nknown ther: <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 of/Year verage Annual Precipitation = 4 0- 25 <br /> )n- Site Wells ) es o umber 8 Type Irr om ub <br /> S Scare 5 Score S core <br /> istance to WeIL ( s ) from Tank ft ; ft ; ft C 10 pts C 9 pts C pis <br /> 0 if 0 if 0 ' f <br /> R ondition R conditicn R ondition <br /> V . Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample ( feet ) > 100 1 - 100 Q 25 - 50N1 <br /> Fractures in subsurface ( applies to foothills or mountain areas ) / O None Unknown Dresent <br /> %verage Annual Precipitation ( inches ) KXXxxX <10 9 10 -25 KXXxmx 26- 4OL <br /> an-Made conduits which increase vertical migration <br /> f leachate ( i . e . , septic systems , water wells , ponds ) None Unknown 3resent <br /> pique site features : Recharge area , coarse soil , or wells . At least ore than <br /> lMuncipaL =>2000 ft ; domestic=>500 ft ; irr/agricultural =present) �Lxx/x1x None one one <br /> COLUMN TOTALS>>>TOTAL POINTS x V + q + <br /> Dom-' ample Result : (B T X OR E ) _ 0 *'� RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> -3 <br /> `t = 3a P " 8 T X E B T X E <br /> f - P 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 /> � ) DOOPFlan. TPM G9 AXIMUM ALLOWABLE TPH LEVELS ( PPM ) <br /> (o TPN D IESEL 10 , 000 1000 100 <br /> FOOTNOTES : *** If docs nted soil and/or ground water contamination is present , do not complete the leaching <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' lf precipitation is > 40 inches , score 0 points . <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm ( gasoline ) or 100 ppm ( diesel ) . <br /> V1 . STAFF RECOMMENDATION/CONCLUSION <br /> 1 . Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o LLG� -� LL��Zy I yJ <br /> 2 . Recommend Site Closure es o if Yes , Refer to Site Miti ga[ ion for EvaluationivL� <br /> V11 . REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES O EFERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> ATE REFERRED G, / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT ) \5/94 •� - <br />