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y SAN JOAQUIN SY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEASDIVISION <br /> 1• UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY I ECORD ID <br /> DRESS ANK ID <br /> ANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? as o ermit # - acility Status Code oc.Soil/GW Cont es o <br /> Number of Tanks at facility ge of Tank(if available) �fype of Tank teel Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? as o ailed precision test ? es o if yes, give date(s) <br /> as a repair made to the tank system? as No f yes, what Was repaired? <br /> as repair done under inspection? Fes o ere soil samples analyzed? es I o I TXE I PH-G I PN-D 1 3 <br /> ype of failure/discharge atastrophic long-term leakage verfill own I ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received as o epth to Ground Water of/Year verage Annual Precipitation = 4 D-25 <br /> -Site Wells) es I o umber & Type Irr an <br /> S Lcore S core S core <br /> istance to Well(s) from Tank ft; ft; ft C C ptsCpts <br /> R ion R ondition R ondition <br /> Site Feature - Leaching Potential Analysis E E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 I 1-100 I 25-50N1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxxxx 26-40L <br /> Man-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 /> (Muncipal=>2000 ft; domestic=>500 ft; irr/agricut tural=present? x None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + a <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 1 T % E e T % E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 -3 1. 1. HA13 <br /> ample Result: SOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTES: --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 /> L If depth is > 5 ft. and < 25 ft., score 0 points. It depth c5 ft., do rot 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 o <br /> I2. Recommend Site Closure as �o I I>If Yes, Refer to Site Mitigation for Evaluation <br /> ✓I I. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> )ATE REFERR 6ATE CLOSURE LETTER MAILED <br /> i <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />