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SAN JOAQU`-•COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL L'-ALTH DIVISION <br /> I' UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> ATE 7��� <br /> AME OF FACILITY /C/6=1,, <br /> L /f` �^w `� WEEPS CODE 77�DRESS (/L// ANK k0 # 7l-ANK SIZE ��1 UEL T <br /> 11. GENERAL SITE HISTORY <br /> Is permit curren[T es o ermit # IF <br /> acility Status Code oc.SoiL/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) u?� ype of Tank teel I y Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested? es ✓ o ailed precision test es o 1f yes, give date(.) / <br /> Jas a repair made to the tank system? es No '/ f yes, what was repaired? <br /> Jas repair done under inspection? es o ere soil samples analyzed? es o TXE PH G PH-D b/EDB <br /> ype of failure/discharge atastrophic long term leakage I loverfilt nknown her: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water of/Year verage Annual Precipitation = 4 0-25 <br /> -Site Wells) es o umber 8 Type Irr om ub <br /> S core S core S core <br /> istance to WeLL(S) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet)50--` - / 1 <br /> 3 >100 1-100 25-50 <br /> Fractures in subsurface (applies to foothills or mountain areal/s) L� None Unknown resent <br /> verage Annual Precipitation (inches) Kxxxxx <10 9 10-25 KXXxxxx 26-40�2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> 10' + 7 Z <br /> i <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> IV B 1 T X E B T X E <br /> C), MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 SO 3 3 1. 1. NA,3 <br /> Sample Result: ASOLINE 1000 100 10 <br /> 60-7 AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH 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 /> L Levels for BTX&E are not applicable at a TPH 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 1Yes o if Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> -VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />