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4 YY <br /> SAN JOAQUIN GTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL„ti DIVISION <br /> 1' UGST WORKSHEET FOR SITE CLOSURE EVALUATIONG <br /> ATE <br /> AME OF FACILITY <br /> L EEPS CODE <br /> 11DRE55 <br /> ANK ID <br /> IANK SIZE ,c/L�U UEL TYPE D� <br /> 11. GENERAL SITE HISTORY <br /> I <br /> Is permit current? es o ermit # - acitity Status Code oe-Soil/GW Cont es <br /> o <br /> umber of Tanks at facility <br /> ge of Tenks(if available} ype of Tank teat FbrgE ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o If yes, give date(s) / /f <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es o ere soil samples ana! zed? es o <br /> Y TXE PH-G , PH-D b/EDB <br /> ype of failure/discharge atastrophic tong-term leakage verfitt nknown lother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS)' <br /> oil Samples Received es v epth to Ground Water U of/Year ; verage Arnual Precipitation E- =0-25 <br /> -Site Wel (s) es a umber & Type Irr om ub <br /> S core S core S core <br /> istance to Wetl(s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> O if 0 if Q { y <br /> R ondition R ondition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soit Sample {feet} >100 1-100 !� 25-50\1 <br /> ractures in subsurface (applies to foothilts or mountain areas) ld None Unknown �If resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 K xxxxxx 26-40\2 <br /> an-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, nearby At least ore than <br /> xxxx None one one <br /> COLUMN TOTALS—TOTAL POINTS l + Xq <br /> + <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or tess <br /> g = -0"3 X= + 30`� <br /> �= i2- 8 i X E B .T <br /> oX E <br /> tf.ia-d�/Y,-] MAXIMUM ALLOWABLE a-T-X-E LEVELS (PPM) 1 50 50 150 .3 3 1- 1. NA\3 <br /> ample Result: GASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> cy TPHIESEE 10,000 ]000 ` 100 <br /> OOTNOTES: *”"If documented soil and/or ground water contamination is present, do not complete the teaching 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., scare 0 points. If depth <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for 8TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 'Ippm (diesel). <br /> 11. STAFF RECOMMENDATION/CONCLUSION <br /> 41 <br /> 1. Are BTX $ E or TPH Concentrations > Attowabte Levels Yes <br /> 2. Recommend Site Ctosure es o If Yes, Refer to Site Mitigation for Evaluation <br /> '11. REVIEW EVALUATION - 70 BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> 1AME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />