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SAN JOAOUIN OTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE JIVIStON <br />-- <br />i. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE J <br />nME OF FACILITY l SWEEPS CODE / V,6 <br />DDRESS TANK ID # - ! G <br />LANK SIZE UEL TYPE fG <br />** <br />>ermit current? esermit # - acitity Status Code Gu Cont s o <br />H <br />Der of Tanks at facility Be of Tanks(if available) ype of Tank Leel Fbrgl ngl Dual <br />til. TANK HISTORY <br />Jas Tank teste( <br />eso <br />IFailed <br />precision test ? <br />as <br />of/Year <br />o <br />If <br />yes, give date(s) <br />4 <br />Was a repair made to the tank system? es No <br />f yes, what was repaired7 <br />es <br />as repair done ender inspection? <br />es o ere soil samples analyzed? <br />es <br />Ember b Type <br />o <br />TXE <br />PH -G <br />PH -0 <br />b/EDB <br />i <br />ype of failure/discharge <br />atastrophic long-term leakage <br />Tyerfitt. <br />known <br />I <br />lother: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received <br />eso <br />epth to Ground Water <br />r <br />of/Year <br />verage Annual Precipitation <br />= <br />4 <br />0-25 <br />-Site Welt(s) <br />es <br />o <br />Ember b Type <br />Irr <br />om <br />ub <br />i <br />S <br />score S <br />Score S <br />core <br />istance to Wett(s) from Tank <br />ft; ft; ft C <br />10 pts C <br />9 pts C <br />pts <br />0 <br />if 0 <br />if 0 <br />f <br />ondition R <br />condition R <br />ondition <br />R <br />Site Feature - Leaching Potential Analysis E <br />is met E <br />is met E <br />s met <br />inimum Depth to groundwater from the Soil Sample (feet) `r <br />>100 <br />1-100 D <br />125-50\1 <br />ractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />oresent <br />verage Annual Precipitation (inches) KXXXXX <br /><10 9 <br />10-25 xxxxxxx <br />26-40\2 <br />an -Made conduits which increase vertical migration <br />f leachate (i.e., septic systems, water welts, 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 />Sample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br />51014 A <br />B <br />T <br />E B <br />X <br />E <br />l3®` <br />L ®� <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 <br />50 <br />Ix <br />50 <br />50 .3 <br />IT <br />.3 1. <br />1. NA\3 <br />Sample Result: <br />ASOLINE 1000 100 10 <br />TPN-J� <br />AXIMUM ALLOWABLE TPN LEVELS (PAM) <br />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 />\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 BTXBE are not applicable at a TPN 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 es o If Yes, Refer to Site Mitigation for Evaluateon 10`1 ��� <br />-ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE rES 0 EFERRED TO SITE MITIGATION FOR EVALUATION fES 0 <br />ATE REFERRED / / �( ATE CLOSURE LETTER MAILED <br />LAME OF <br />:VALUATOR U - <br />ru 11 An iucrvrcuT%%Cion <br />