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SAN JOAQU1JNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H,� DIVISION <br /> 4� <br /> (, UST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> AME OF FACILITY ECORD ID <br /> ADDRESS ANK ID # <br /> i <br /> TANK SIZE I IFUEL TYP J! 7.0a <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # - acility Status Code 9 y oc.Soil/GW Cont es o <br /> umber of Tanks at facility kge of Tank(if available) f 7 ype of Tank IS <br /> teel brgl Dual <br /> III. TANK HISTORY J ` <br /> as Tank tested? es I o ailed precision test ? es o If yes, give date(s)7/ <br /> as a repair made to the tank system? IYes No I yff yes, what was repaired7 <br /> as repair done under inspection? es ere soil samples analyzed? es o I TXE PH-G I PH-D b/EDB <br /> ype of failure/discharge atastrophiclF long-term leakage verfill known ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received eso epth to Ground Water of/Year cJ3 verage Annual Precipitation k= 4 0-25 <br /> n-Site Wells) es o umber & Type Irr I yfom ub <br /> S Score S Score S Score <br /> istance to WeLL(S) from Tank ft; /-SO ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R rondition R condition R rondition <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 �S 25-50L <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> Average Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26-4012 <br /> Ian-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, or wells. At least 4ore than <br /> LMuncipaL=>2000 ft; domestic=>500 ft; irr/agricultural=present] Kxxxxx None 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 /> 90i S7 <br /> E z3*1 y70 i ep BT X E B JT X E <br /> '>070 , ZUC1! MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL3 <br /> Sample Result* ASOLINE 1000 100 10 <br /> QTcp aP: l3�/ i9�/ AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 6 g 00 _ 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 /> 11 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> L If precipitation is > 40 inches, score 0 points. <br /> 13 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 V10 <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES 140 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)\5/94 <br />