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�j <br /> SAN JOAQ4,,6k,, PUBLIC HEALTH SERVICES/ENVIRONMENTAL 7'r. _1VISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE'EVALUATION <br /> AME OF FACILITY SWEEPS CODE Z3 <br /> DDRESS TANK ID it <br /> TANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> w* <br /> Is permit current? es o ermit it acility Status Code oc.Seil/Gil Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank tee( brgl ngl Dual <br /> 171. TANK HISTORY <br /> as Tank tested? as i� o ailed precision test 7 eso If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> ns repair done under inspection7 <br /> es o ere'soil samples analyzed? es Jo TXE PH-G PH-D b/EDB <br /> .i <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received as o I epth to Ground Water of/Year verage Annual Precipitation 4 10-25 <br /> in-Site Well(s) eso umber & Type Irr om ub <br /> 5 Score S Score S core <br /> istance to Weti(s) from Tank ft; ft; ft C 10 pts C 9 pts C i pts <br /> 0 if 0 if 0 f <br /> R condition R condition R ondition <br /> V. Site Feature - LeachIIng Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50\1 <br /> ractures in subsurfacei!(applies to foothills or mountain areas) None Unknown Dresent <br /> verage Annual Precipitation (inches) xxxxxx 00 9 10.25 xxxxxxx 25-40\2 <br /> an-Made conduits which ;incresse vertical migration <br /> f leachate (i.e., septic systems, water welts, ponds) None Unknown resent <br /> lnique site features: Recharge area, coarse soil, nearby Wells. At (east 40re then <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + + <br /> i <br /> ampleN Res LZ�t. (B T X OR:E) RANGEiOF TOTAL POINTS 9 ,pts or more 41 48 pts 40 pts or less <br /> Z X.15-ZX ))bz <br /> T'DS5 ^ `0b4 11 T I XE 8 JT tXI E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> ample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH-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 /> Ij 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'. it depth <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, scare 0 points. <br /> \3 Levels for BTX&E are not applicabte 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 /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION TO BE C014PLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VALUATOR <br /> i EH 23 80 (UGTWKSHT)\5/90' <br /> EH 29 80 F <br />