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SAN JOAQUIN 'aNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEATTH DIVISION <br /> 1 UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY <br /> - SWEEPS CODE v /wCZ— 111 <br /> "DRESS /ZL1 TANK ID # <br /> TANK SIZE <br /> UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> P <br /> Is permit current? C5 IN o ermit # I acility Status Code :?g-, oc.Soil/GW Cont o <br /> umber of Tanks at facility %ge of Tanks(if available) IType of Tank ISteel I Fbrgl ngl I Duat <br /> III. TAMX HISTORY <br /> Was Tank tested? Ifes x o ailed precision test ? es INO If yes, give date(s) <br /> Jas a repair made to the tank system? Yes No f yes, what was repaired? <br /> ns repair done under inspection? es o ere soil samples analyzed? es X 10 TXE PN-G PH-D X b/EDB <br /> ype of faiture/discharge atastrophic long-term leakage verfill nknown 1 10ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es 190 epth to Ground Water 70 of/Year verage Annual Precipitation <br /> On-Site Wells) es o umber & Type 1" om I ytub <br /> S Score S Score S Score <br /> istance to Welt(s) from Tank 'fj� *ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> J. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimxxn Depth to groundwater from the Soil Semple (feet) >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown Dresent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> Df teachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> inique site features: Recharge area, coarse soil, nearby wells. 4 At least lore than <br /> xxxxx None i one one <br /> COLUMN TOTALS»>TOTAL POINTS + + <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B I T X B T X E <br /> AXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 150 .3 .3 1. 1. <br /> NA\3 <br /> Sample Result: ASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not cow 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 /> \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 I INO <br /> 2. Recommend Site Closure 1Y <br /> es IATO <br /> If Yes, Refer to Site Mitigation for Evaluation <br /> VTI. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE VES 0 EFERRED TO SITE MITIGATION FOR EVALUATION YES JO <br /> ATE REFERRED 1� / / ATE CLOSURE LETTER MAiLEO <br /> AME OF ` ���C/+✓'� v- ' CT <br /> :VALUATOR �/►—J <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />