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SAN JOAQU NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL TH DIVISION <br /> I. UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY RECORD ID <br /> ADDRESS TANK ID # - <br /> TANK SIZE IFUEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current? Ires 1 1401 ermit # - acility Status Code oc.Soit/GW Cont es o <br /> Number of Tanks at facility ge of Tank(if available) ype of Tank teen brgl ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? Ifes, IN01 IF <br /> ailed precision test ? es o If yes, give dates) <br /> as a repair made to the tank system? es No 11f yes, what was repaired? <br /> as repair done under inspection? es No ere soil samples analyzed? es o TXE I PH-G I PH-D b/EDB <br /> ype of failure/discharge atastrophic long-tern leakage Everfill nown they: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es I IN01 epth to Ground Water of/Year verage Annual Precipitation <br /> 3n-Site Well(S) Ifes o umber & Type 11 r am ub <br /> S Score S Score S core <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R ondition 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 25-50L <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-402 <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 /> (Muncipal=>2000 ft; domestic=>500 ft; irr/agricultural=present] xxxxxx 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 /> B T X E B JT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAL <br /> ample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPN 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 /> \2 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 o <br /> 2. Recommend Site Closure eso If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES I IND <br /> EFERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />