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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA0W01VISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AMC OF FACILIT' EEPS CODE <br /> DORE$$ AN K ID # <br /> ANK SIZE UL TYPE 41, <br /> 11. GENERAL SITE NISTA Y <br /> 111. TANK HISTORY <br /> las Tank tested? as 0 ailed <br /> as a repair made to the tank syst <br /> ns repair done under inspection? e xe Pfi-G PH-D WEDS <br /> ypo of failure/discharge atastrosic Ong, em tea ase yer n n ra tnerl: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> crit samtes A 1( verage Annual Precipitation = 4 Ill- <br /> -Sits WOMS <br /> S core S core S core <br /> istance to Wptdts> fr Tank f I ftg ft C 0 Pts C PIS C Its <br /> 0 if 0 if 0 <br /> It ondition A ondition R ondition <br /> Site feature - Leaching Potential AnalySis E is n E is met E <br /> Watum Depth to gtour4water from the Soit SaMte (feet) >100 <br /> ractures in subsurface (applies to foothilts or motntai areas) /0 None Un rr resent <br /> verage Annuat Precipitation (inches) xxxxx 00 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical Migration <br /> teachate (i.e., septic systems, water wetts, ponds) None Unknown resent <br /> Wque site features: Recharge area, coarse soil, nearby wetts. At least We than <br /> xxxxx None one one <br /> COLUMN TOTAL TOTAL POINTS + ISO + 05 &_3 <br /> ampte Results (8 T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> 6 ;K <br /> 8 T X E 8 T X E <br /> MAXIMUM AL 1 50 50 50 1. �N A\:3;1) <br /> �ample Resutt. ASt1LINE 1000 100 10 <br /> ;z?4)'0 AXIMUM ALLOWAS <br /> TPH IESEL 1C,CCC 1000 (1 00 <br /> OOTNOTES: ***If documntod shit and/or ground water contwOnatiara is present, do not cmptete the teaching potential <br /> anatyals. (i.e., site Is currently on U Contamination List for soft or ground water.) <br /> 11 If depth is v 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 SWE are not appticaitte at a TPH concentration of 10 ppm (9asotine) or 100 ppo (diesel), <br /> V1. ST FR RECOMMENDATION/CONCLUSION <br /> 1.=Are STX & E or T Concentrations > Allowableiiia <br /> 2 "T)' <br /> Site 1 i: , :� i If Yes, Refer to Site Mitigation Ifor Evaluation <br /> 2. Recomffamend <br /> Vll„ REVIEW EVALUATION TO BE WiPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH StAfF RECOMMENDATION FOR CLOSURE ES EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> )ATE REFERPED ATE CLOSURE LETTER MAILED <br /> AME OF <br /> 'VALUATOR <br /> EN 23 80 (UGTWK$HT)15/90 <br /> PH 29 80 <br />