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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY SWEEPS CODE <br /> DDRESS TANK ID # <br /> TANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # acility Status Code oc.Soil/GW Cont es J0 <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank tee( Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? eslNol IF <br /> ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? es No IIf yes, what was repaired? <br /> Jas repair done under inspection? 1Yes I No ere soil samples analyzed? 1Yes 10 TXE ITPH-G I ITPH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakageverfilL nknown ther: <br /> 1V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .oil Samples Received Ifes I IN01 epth to Ground Water of/Year verage Annual Precipitation = 4 10.25 <br /> Site Wells) es 1 o umber & Type Irr om ub <br /> S core S Score S Score <br /> istance to WeIL(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (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) KXXXXX <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) None Unknown Dresent <br /> lnique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS F9 pts or more 41 48 pts 40 pts or Less <br /> B T X E B JT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> -ample Result: ASOL(NE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ***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 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 1401 1 <br /> 2. Recommend Site Closure 1Y <br /> es o if Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES I IN01 <br /> EFERRED TO SITE MITIGATION FOR EVALUATION ES �0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED / ! <br /> AME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />