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OF FACILITY <br />SS <br />�IANK SIZE <br />11. GENERAL SITE HISTORY <br />SAN JOACUIN4m,. .iY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE DIVISION <br />UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 2 Q <br />EEPS CODE <br />ANK ID # - <br />EL TYPE / N/23 <br />,e* <br />permit current? es o ermit # - acidity Status Code -Soi / W Cont es o <br />fiber of Tanks at facility I C2 kge of Tanks(if available) ype of Tank teel I Fbrgt ngl I Dual <br />as Tank tested? <br />bs <br />I <br />o <br />ailed precision test ? <br />es <br />EFERRED TO SITE MITIGATION FOR EVALUATIO <br />o <br />if <br />yes, give date(s) <br />k= <br />Jas a repair made to the tank system? es No 1 <br />11f yes, what was repaired? <br />-Site Wetl(s) <br />as repair done under inspection? <br />es o <br />ere sail samples analyzed? <br />es <br />umber & Type <br />o <br />TXE <br />I <br />PH -G <br />ub <br />PH -0 <br />b/EDB <br />ype of failure/discharge <br />atastrophictong-term <br />leakage <br />verfill <br />nknown <br />ther: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />oil Samples Received <br />es <br />rES1 <br />o <br />0 <br />epth to Ground Water <br />EFERRED TO SITE MITIGATION FOR EVALUATIO <br />of/Year <br />I a& ; 6 1, <br />verage Annual Precipitation <br />k= <br />4 <br />0-25 <br />-Site Wetl(s) <br />IYes <br />1 <br />14, <br />1 <br />umber & Type <br />Irr <br />I <br />om I <br />ub <br />S <br />Score S <br />Score <br />S <br />core <br />istance to Welt(s) from Tank <br />ft; ft; ft C <br />10 pts C <br />9 pts <br />C <br />pts <br />0 <br />if 0 <br />rondition R <br />if <br />condition <br />0 <br />R <br />f <br />ondition <br />R <br />V. Site Feature - Leaching Potential Analysis E <br />is met E <br />is met <br />E <br />s met <br />inimum Depth to groundwater from the Soil Sample <feet) <br />>100 <br />1-100 <br />25-50\1 <br />ractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />>resent <br />verage Annual Precipitation (inches) KXXXXX <br /><10 9 <br />10-25 <br />xxxxxx <br />26-40\2 <br />an -Made conduits which increase vertical migration <br />f leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />resent <br />pique site features: Recharge area, coarse soil, nearby wells. <br />At least <br />lore than <br />xxxx <br />None <br />one <br />one <br />COLUMN TOTALS>>>TOTAL POINTS <br />+ <br />+ <br />ample Result: (B T X OR E) <br />r -0ea P -'9ra <br />®®5 aB <br />RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts <br />40 pts or less <br />T <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 <br />X <br />15O <br />E B T <br />50 .3 1.3 <br />X <br />1. <br />E <br />1. <br />NA\3 <br />ample Result: <br />ASOLINE 1000 100 <br />10 <br />TPH <br />AXIMUM ALLOWABLE TPH LEVELS (PPM) <br />IESEL 10,000 1000 <br />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 />\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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline)__or diesel). <br />V1. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX $ E or TPH Concentrations > Allowable Levels Yes o <br />2. Recommend Site Closure es I ito <br />If Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO BE CCMPLETED BY A SUPERVISOR/SENIOR <br />.ONCUR WITH STAFF <br />RECOMMENDATION FOR CLOSURE <br />rES1 <br />0 <br />I <br />EFERRED TO SITE MITIGATION FOR EVALUATIO <br />0 <br />ATE REFERRED <br />�/ / �,( <br />ATE CLOSURE LETTER MAILED <br />JAME OF <br />:VALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />