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SAN JOAQUIN CoPUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALT "ISION <br /> I. UST WORKSHEET FOR SITE CLOSURE.r VALUATION ATE z <br /> AME OF FACILITY ( ECORD ID <br /> DRESS (' ANK ID # - <br /> ANK SIZE IFUEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit lFacility Status Code oc.Soil/GW Cont IYes o <br /> umber of Tanks at facility ge of Tank(if available) ype of Tank teel Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> �as Tank tested? es o ailed precision test ? es o If yes, give date(s) <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 analyzed? es o TXE PH-G PH-D 1b/EDB <br /> ype of failure/discharge tastrophie long-term leakage verfiII the,: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oiL Samples Received es o epth to Ground Water of/Year ; erage Annual Precipitation = 4 0-25 <br /> n-Site WeIL(s) IYes o unbar & Type 11r an ub <br /> S score S Score S core <br /> istance to WeLL(s) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R onditian R condition&26-40 <br /> Site Feature - Leaching P nt' Analysis E is met E met <br /> inimum Depth to groundwa t 10 -1 CL <br /> �ractures in subsurface (applies to foothills or mountain areas) None Unknownverage Annual P o t ) <10 9 <br /> an-Made co its i rea vertical migration <br /> f leachateseptic systems, water wells, po None Unknown resent <br /> I <br /> nique site , coarse soil, or wells. At least ore than <br /> s <br /> [MuncipaL=> f ; tic=>500 ft; irr/agricuLtYaL=vrsentJ x None one one <br /> kffl��TOTALS»>TOTAL6!5 <br /> a + <br /> ample 31vuLt: (B T OR®E2 RANGE OF i6TAff PNRINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> B T X E B T X E <br /> MAXIMtfit L it, <br /> B-T-X- S PPM) 1 SO 50 50 .3 3 1. 1. NAL3 <br /> ample Result: CLINE 1000 100 10 <br /> IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPN 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 /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> 12 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 /f <br /> 1. Are BTX & E or TPN Concentrations > Allowable Levels Yes <br /> 2. Recommend Site Closure es o if Yes, Refer to fite Mitigation for Evaluation V(4�c <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> 1 <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES I 0 I IZEFERRED TO SITE MITIGATION FOR EVALUATION fES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />