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SAN JOAQUIN CCUHTY LIC HEALTH SERVICES/ENVIRCHMENTAL HEALTH A ON <br />• UGST WCRXSHEET FOR SITE CLOSURE EVALUATION? 3ATE „► <br />AME OF FACILITY" aga SWEEPS CODE <br />1t�d <br />�ADRESS AHx t0 x <br />tANX SIZE ®� 1 0 UEL TYPE <br />I. GENERAL SITE (STORY ff <br />tS permit current? eso ermic S - aeitity Status Code oc.Scit/GW Cont es o' <br />umber of Tanks at facility it kge of Tanks(if available) of Tank teal brgl rgl Oval <br />I i. �nnw ni.. simi <br />as Tank tested7 11es1. <br />o <br />epch to Ground Water <br />ailed precision test ? <br />es <br />verage Annual Precipitation <br />o <br />if <br />yes, give date(s) <br />-Site Weil(s) <br />as a repair made to the tank system? es No lif yes, what was repaired? <br />'ns repair done under inspection? es oFere soil samples analyzed7 es <br />o <br />o <br />r b Type <br />TXE <br />PH -G <br />PH -0 <br />bnos <br />ype of failure/discharge <br />atastrophic -term Leakage <br />verfitl <br />cher: <br />V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE OCTAILS/COLIZT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />it Samples Received es <br />o <br />epch to Ground Water <br />of/Tear <br />I Iq ; <br />verage Annual Precipitation <br />= <br />4 <br />0.25 <br />-Site Weil(s) <br />es <br />o <br />r b Type <br />Irr <br />om <br />b <br />S <br />core S <br />0 pts C <br />core S <br />pts C <br />core <br />pts <br />istance to Watt( from from Tank <br />ft; ft; ft <br />C <br />0 <br />f 0 <br />ondition R <br />is met E <br />if 0 <br />condition R <br />is met E <br />f <br />onditian <br />s met <br />R <br />i. Site Feature - Leaching Potential Analysis <br />E <br />iinimtm Depth to groundwater from the Soit Saapte (feet) <br />)'100 <br />1-100 <br />25.50\1 <br />roc:urea in subsurface (apptfes to foothills or mountain areas) <br />Nine <br />Unknown <br />3resent <br />I►verage Annuat Precipitation (inches) xxxxxx <br /><10 9 <br />10-25 xxxxxxx <br />26-40\2 <br />an -Made conduits which increase verticat migration <br />f leachate (i.e., septic system, water welts, ponds) <br />None <br />Unknown <br />3resent <br />ique site features: Recharge area, coarse soil, nearby welts. <br />At least <br />4oce than <br />xxx <br />None <br />one <br />one <br />COLUMN TOTALS»>TOTAL POINTS <br />+ <br />+ <br />ample Resutt: (a T X OR E) RANGE OF TOTAL POINTS <br />9 pts or more 41 - 48 pts 40 pts or less <br />B T X E B t X E <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPH) <br />1 50 50 15O .3 3 1. 1. HA\3 <br />1 <br />SampEe Result: OLIN <br />1000 100 10 <br />IMJH ALLOWABLE TPH LEVELS CPPN) <br />E <br />TPH 11rlESEL <br />10,000 =1000100 <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 soit 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 />\2 If precipitation is > 40 inches, score 0 points. <br />\3 Levels for 3TX3E are not applicable at a TPH concentration of 10 Pisa (gasoline) or 100 ppm (dieset). <br />!. STAFF R£CCMHENOATION/CCHCLUSION <br />1 C. xecommern SI re 6t6sure I1 CS I ru I L iea, nci ce <br />'I. REVIEW EVALUATION - TO BE CCKPLETED BY A SUPERVISOR/SENICR <br />DNCUR WITH STAFF RECCHMENDATION FOR CLOSURE <br />ATE REFERRED <br />=ALUATCR <br />• EX 23 BO (UGTWXSHT)\5/90 <br />EFERRED TO SITE MITIGATION FOR EVALUATION <br />CLOSURE LETTER MAILED <br />