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-TA N 1< <br /> SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION -- -- <br /> - <br /> AME OF FACILITY ^ rn„� t/tom T EEPS CODE <br /> DRESS 26%b �k A1` ANK ID # - / —3 9 <br /> GENERAL SITE HISTORY <br /> Is permit current? es o ermit lFacitity Status Code 9 6 oc.Soil/GW Cont es o <br /> umber of Tanks at facility kge of Tanks(if available) U p r-- ype of Tank 13teel ✓Fbrgl ngl Dual <br /> TANK HISTORY <br /> Jas Tank tested? es ✓ o ailed precision test ? as o If yes, give date(s) 1 g/ 2 /BCI', <br /> as a repair made to the tank system? Yes No14 f yes, what was repaired? <br /> Jas repair done under inspection? es No ere soil samples analyzed? es o I JTXE I PH-G I PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nown ther: <br /> 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 2oof/Year o� USO verage Annual Precipitation k= 14- 0-25 <br /> -Site WeLI(s) es I o ,✓ umber & Type 11 r om ub <br /> S core S Score S Score <br /> istance to Wells) from Tank ft; ft; ft C 0 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 -f <br /> R ondition R condition R ondition <br /> ite Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) p%jp >100 1-100 0 25-50_\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-4012 <br /> an-Made conduits which increase vertical migration <br /> f Leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> None one one <br /> COLUMN TOTALS>>>TOTAL POINTS ( ; Z + 0 <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or, less <br /> BT I X E B T X E <br /> Aj MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1 NA_\3 <br /> Sample ResutL•_,c1 /'M 1000 100 10 <br /> o <br /> V I"T AXIMUM ALLOWABLE TPH LEVELS (PPM) SOLINE <br /> _{ IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the lea. i ial <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 /> 12 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 /> STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH ConcentratiM> Allowable Levels YesIN <br /> o 7 <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR III` <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ESO <br /> EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR t <br /> EH 23 80 (UGTWKSHT)\5/90 <br />