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SAN JOAQUIN C.0 PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL•IVlSION <br />T, UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br />AME OF FACILITY : FOOD &Afr <br />WEEPS CODE <br />DDRESS J UIc ���TANK ID # - <br />TANK SIZE �S� UEL TYPE C-jC)S- <br />I1. GENERAL SITE HISTORY <br />xx <br />Is permit current7 es o1 V1 ermit # - acility Status Code �y' oc.Soil/GW Cont 1Y <br />es o <br />umber of Tanks at facility ge of Tanks(if available) I IT <br />ype of Tank teel Fbrgl ngl Dual <br />III. TANK HISTORY <br />as Tank tested? <br />Ires <br />I VIN <br />o <br />epth to Ground Water <br />ailed precision test ? <br />es <br />j4. � <br />o <br />'--11 <br />f yes, give date(s) <br />0-25 <br />as a repair made to the tank system? Yes No <br />f yes, what was repaired? <br />LAME OF <br />VALUATOR <br />'as repair done under inspection? <br />es r4c� qo <br />If <br />I ere soil samples analyzed? 1Yes <br />o <br />I <br />PTXE <br />I <br />PH G <br />PH -0 <br />b/E08 <br />ype of failure/discharge <br />atastrophic <br />long-term leakage <br />verfill <br />nknown <br />I <br />they: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />oil Samples Received <br />1Yes <br />I VIN <br />o <br />epth to Ground Water <br />c <br />of/Year <br />j4. � <br />verage Annual Precipitation <br />N= <br />11 4 <br />0-25 <br />n -Site WeLI(S) <br />es I <br />LAME OF <br />VALUATOR <br />IJ1o <br />umber 8 Type <br />Irr <br />cm <br />I <br />ub <br />S <br />C <br />core <br />10 pts <br />S Score <br />C <br />9 pts <br />S <br />C <br />9core <br />pts <br />istance to Wells) from Tank <br />ft; ft; r ft <br />0 <br />R <br />E <br />if <br />condition <br />is met <br />0 if <br />R condition <br />E <br />is met <br />0 <br />R <br />E <br />f <br />ondition <br />is met <br />V. Site Feature - Leaching Potential Analysis <br />inimum Depth to groundwater from the Soil Sample Veet) <br />>100 <br />1-100 <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />resent <br />verage Annual Precipitation (inches) <br />xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxxxxx <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 />iore than <br />xxxx <br />None <br />one <br />one <br />COLUMN TOTALS>>>TOTAL POINTS <br />6 <br />2 <br />ample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />P pts or more <br />41 - 48 pts <br />40 pts or less <br />B <br />T <br />X <br />E <br />B <br />T <br />X <br />E <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />1 <br />50 <br />1 <br />50 <br />50 <br />.3 <br />.3 <br />1. i <br />1. <br />NA\3 <br />ample Result: <br />SASOLINE <br />1000 <br />100 <br />10 <br />AXIMUM ALLOWABLE TPH LEVELS (PPM) <br />IESEL <br />1 10,000 <br />1000 <br />100 <br />TPN <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 TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOFMfENDATION/CONCLUSION <br />I�a-a = • 2 rt -4j 1� <br />1. Are BTX $ E or TPH Concentratio s > Allowable Levels Yes e <br />2. Recommend Site Closure 1Y <br />es V <br />o If Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />-ONCUR WITH STAFF R£CCMMENOATION FOR CLOSURE <br />fES <br />0 <br />EFERRED TO SITE MITIGATION FOR EVALUATION ES <br />O <br />)ATE REFERRED <br />/ / <br />ATE CLOSURE LETTER MAILED <br />LAME OF <br />VALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />