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SAN JOAQt- COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL EALTH DIVISION <br /> 1' UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY �f�QCf L, /-/7�0 �--� WEEPS CODE J��- <br /> DRESS �G I/�/ � !C/fCTANK FD # �/'/ / 7T—Z) <br /> ANK SIZE 0 Q G UEL TYPE - �1 <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ✓ ermit # - aciIity Status Code oc.Soit/GW Cont es o <br /> umber of Tanks at facility 7 ge of Tanks(if available) ype of Tank teel Fbrgl ngl Dual <br /> lll. TANK HISTORY <br /> as Tank tested? es o ailed precision test 7 es o If yes, give date(s) <br /> as a repair made to the tank system? es No 11f yes, what was repaired7 <br /> as repair done under inspectionesere soil samples analyzed7 es o TXE IT <br /> PH-G I PH-D b/EDB <br /> yo pe of failure/discharge atastrophic long-term leakage FFrfLt nknown I lo <br /> cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es I IN01 epth to Ground Water of/Year ; �qt�f verage Annual Precipitation = 4 0 25 <br /> Site Well(s) es o \ umber & Type Irr om ub <br /> S Score S I Score S 3core <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 3 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysisj L r-- I(�=��, E is met E is met E 's met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-5011 <br /> Fractures in subsurface (applies to foothills or mountain areas) J T1 None Unknown resent <br /> verage Annual Precipitation (inches) Kxxxxx <10 9 10-25 KXXxxxx 26-40L <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown 3resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS J L,' + + <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 = 48 S_ 40 pts or less <br /> T MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 81 50 50 50 .3 .3 1 1. NA,3 <br /> Sample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> pH DIESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not nplete [t)f Teaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soi --or ound water.) <br /> L If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> ,12 if precipitation is > 40 inches, score 0 points. <br /> L 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 Yes0 I IN <br /> 2. Reconmend Site Closure 1Y <br /> es I o v//!f Yes, Refer to Site Mitigation_for EvaluationD <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR Q <br /> C j <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES 0 EFERRED TO SITE MITIGATION FOR EVALUATION fES 0 <br /> ATE REFERRED DATE CLOSURE LETTER MAILED <br /> AME OF <br /> -VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />