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SAN JOAQUIN 'A PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALT. _.JISION <br />I. UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br />AME OF FACILITY I ECORD ID <br />DRESS ANK ID # T- <br />FANK SIZE I IUEL TYPE <br />permit current? es o ermit # - acuity Status Codeoc.Soil/GW Cont es o <br />ber of Tanks at facility ge of Tank(if available) (Type of Tank teel it <br />Ong[ Duat <br />III. TANK HISTORY <br />as Tank tested7 <br />es <br />INO <br />o <br />epth to Ground Water <br />sited precision test ? <br />es <br />o <br />k= <br />If yes, give date( s) <br />/ / <br />as a repair made to the tank system? es <br />No Irf yes, what was repaired7 <br />as repair done under inspection? es <br />No ere soil samples analyzed7 es o TXE I PH -G I PH -D b/EDB <br />�ype of failure/discharge <br />S <br />C <br />0 <br />R <br />E <br />atastrophic <br />tong -term leakage <br />Score <br />9 pts <br />if <br />condition <br />is met <br />verfill <br />core <br />pts <br />'f <br />ondition <br />s met <br />norm <br />ther: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />oil Samples Received es I <br />ES 0 <br />INO <br />ATE REFERRED I / / PATE CLOSURE LETTER MAILED <br />epth to Ground Water <br />of/Year <br />verage Annual Precipitation <br />k= <br />4 0-25 <br />n -Site Wetl(s) es I <br />umber & Type <br />Irr <br />am ub <br />S <br />C <br />0 <br />R <br />E <br />Score <br />10 pts <br />if <br />ondition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />9 pts <br />if <br />condition <br />is met <br />S <br />Ci <br />0 <br />R <br />E <br />core <br />pts <br />'f <br />ondition <br />s met <br />istance to Well(s) from Tank ft; ft; ft <br />N. Site Feature - Leaching Potential Analysis <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />I <br />1-100 <br />25-5011 <br />fractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />resent <br />verage Annual Precipitation (inches) <br />KXXXXX <br /><10 <br />9 <br />( 10-25 <br />xxxxxxx <br />26-4012 <br />an -Made conduits which increase vertical migration <br />f leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />Dresent <br />nique site features: Recharge area, coarse soil, or wells. <br />[MLncipal=>2000 ft; domestic=>500 ft; irr/agricut tura l=present) FIXxxxx <br />None <br />At least <br />one <br />4ore than <br />one <br />COLUMN TOTALS» >TOTAL POINTS <br />+ <br />i <br />1 <br />+ I <br />ample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />9 pts or more <br />41 - 48 pts <br />40 pts or less <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />B 7 X E <br />1 50 50 50 <br />B IT X E <br />.3 .3 1. 1. <br />NA13 <br />�ampte Result: <br />TPH <br />AXIMUM ALLOWABLE TPH LEVELS (PPM) <br />rSCILINE <br />1000 <br />100 <br />10 <br />SEL <br />10,000 <br />1000 <br />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 />11 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br />\22 If precipitation is > 40 inches, score 0 points. <br />\3 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 LevetsYes o <br />2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br />ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 I EFERRED TO SITE MITIGATION FOR EVALUATION <br />ES 0 <br />ATE REFERRED I / / PATE CLOSURE LETTER MAILED <br />AME OF <br />VALUATOR <br />EH 23 80 (UGTUKSHT)\5/94 <br />