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I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I- UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE P `�- CL <br />! AME OF FACILITY � l ff y <br /> lJ��s f l 11,',tI("'SLS `,, IVL,L SWEEPS CODE <br /> DRESS b V"�5! S61LO �40 TANK ID # 55-'� <br /> ANK SIZE �O UEL TYPE ` <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # - acility Status Code oC.SoiI/GW Can es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tankreel rb,rgt ngl Dual <br /> ,F <br /> 1I1. TANK HISTORY r GJ g� <br /> Jas Tank tested? es o I J'_ <br /> iled precision test 7 es o If yes, give date(s) <br /> Jas a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? e$ No ere $oil samples analyzed? es o TXE P4-G] PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakverfil! nknown they: <br /> age <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> r <br /> 01l Samples Received eso epth to Ground Water ,i of/Year verage Annual Precipitation = 4 0-25 41 611 1 <br /> -Site WetL(s) es o umber & Type Err om b <br /> 5 Score 5 Score S Score <br /> istance to WeLL(S) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 f <br /> R ronditioni R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met '. E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 II1 25-50L <br /> Fractures in subsurface (applies to foothills or mountain areas) 4 None Unknown Present <br /> %verage Annual Precipitation (inches) xxxxxx <10 9 10-25 , xxxx 2G-401,2• <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown ,r resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At Leasrore than <br /> - - xxxx None one S one <br /> COLUMN TOTALS»>TOTAL POINTS 1b + � � + 'I� ID <br /> Sample Result: (B`Tf X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> a= DLJ3 h •36 B T X E 8 X EI'i2 MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 150 5D 50 .3 J.T <br /> 3 1. 1. NA13 <br /> Sample Result: SOLINE 1000 100 F 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH 1,� 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 sail or ground water.) <br /> L 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 ,100n ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION 1 p{ (�lraVC� Qrmor� <br /> Lids Olaserued <br /> 1. Are BTX & E or TPH Concentrations > Atlowable Levets Yes I V�o <br /> 2. Recommend Site Closure es I Jo-L.-Jif Yes, Refer to Site Mitigation for EvaLuat on <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR ) <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION E5 O <br /> F <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> �- <br /> EH 23 80 (UGTWKSHT)\5/90 ` <br />