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SAN JOAQUIN MINTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HES,. DIVISION <br /> 1- UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY EEPS CODE I <br /> DDRESS Z F-tA,Lf ITANK ID # r ?-0on r <br /> TANK SRE -a?' UEL TYPE `( <br /> II. GENERAL SITE HI KORY <br /> Is permit current? es o ermit # lFacitity Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility Be of Tanks(if available) IType of Tank teal Fbrgl I ISngl I Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o IF ailed precision test ? as o If yes, give date(s) / <br /> as a repair made to the tank system? as No f yes, what was repaired7 <br /> as repair done under inspection? es o ere soil samples analyzed? as I Jo I TXE I PH-G PH-D I b/EDD <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown then: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .oil Samples Received as o epth to Ground Water of/Year �,; ; v age Annual Precipitation = 4 10-25 <br /> -Site weli(s) es o IV umber 8 Type Irr am .ub <br /> S core S Score S Score <br /> istance to Wetl(s) from Tank I ft; ft; ft - C 0 pts L 9 pts C 5 pts <br /> 0 'f 0 if 0 if <br /> R aditi on R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater frau the Soil Sample (feet) 100 1-100 _�� 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxxx <10 9 10-25 xxxxxx 26.40\2 <br /> nn-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None — Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. �' At least 4ore than <br /> XXXXX None one one <br /> /I <br /> COLUMN TOTALS»>TOTAL POINTS c+ + <br /> 'ample exult: (D T X OR E) RANGE OF TOTAL POINTST9 pts or more 41 - 48 pts 40 pts or Less <br /> /�l✓n D'z u M B T X E 6 T % E <br /> alp MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> -ample Res{it• >ry,�✓ ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTES: ***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 BT%8E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes 1401 <br /> 2. Recommend Site Closure as o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE C04LETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES I LYO I EFERRED TO SITE MITIGATION FOR EVALUATIONES !0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> -VALUATOR l <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />