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It. <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br />I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br />AME OF FACILITY -� !� ,�� WEEPS CODE <br />DDRESS 7%/ S 5+..L(' ANK ID # <br />ANK SIZE I (C)O UEL TYPE , <br />III. TANK HISTORY <br />as Tank tested? <br />es <br />ES <br />o <br />0 <br />ailed precision test ? <br />as <br />of/Year <br />o <br />if <br />yes, give date(s) <br />** <br />as a repair made to the tank system? as No f yes, what was repaired7 <br />xrmit current? <br />Ires <br />es I qo <br />o <br />es <br />ermit # <br />acility Status Code <br />T%E <br />I <br />oc.Soil/GW <br />Cont <br />es <br />I <br />No <br />xr of Tanks at facility <br />ype of failure/discharge <br />ge of Tanks(if available) <br />atastrophic <br />ype of Tank <br />IStest <br />verfiLl <br />Fbrgl I <br />ISngl <br />Dual <br />III. TANK HISTORY <br />as Tank tested? <br />es <br />ES <br />o <br />0 <br />ailed precision test ? <br />as <br />of/Year <br />o <br />if <br />yes, give date(s) <br />4 <br />as a repair made to the tank system? as No f yes, what was repaired7 <br />-site Well(s) <br />ns repair done under inspection? <br />es I qo <br />ere soil samples analyzed? <br />es <br />umber 8 Type <br />to <br />T%E <br />I <br />PH -G <br />I <br />PH -D <br />Score S Score S <br />10 pts C 9 pts C <br />if 0 if 0 <br />onditi on R condition R <br />is met E is met E <br />17b/EDB <br />istance to Wells) from Tank <br />ype of failure/discharge <br />atastrophic <br />long-term leakage <br />-- <br />verfiLl <br />25-50\1 <br />nknown <br />I <br />ther: <br />io <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received <br />es <br />ES <br />o <br />0 <br />epth to Ground Water <br />11M <br />of/Year <br />0 <br />INveroge Annual Precipitation <br />A= <br />4 <br />10-25 <br />-site Well(s) <br />es <br />1 11o <br />ATE CLOSURE LETTER MAILED <br />umber 8 Type <br />Irr <br />om <br />ub <br />S <br />C <br />0 <br />R <br />E <br />Score S Score S <br />10 pts C 9 pts C <br />if 0 if 0 <br />onditi on R condition R <br />is met E is met E <br />Score <br />5 pts <br />if <br />ondition <br />is met <br />istance to Wells) from Tank <br />ft; ft; ft <br />' <br />V. Site Feature • Leaching Potential Analysis <br />inimum Depth to groundwater from the Soil Sample (feet) =rY <br />-- <br />>100 1-100 <br />25-50\1 <br />ractures in subsurface (applies to foothills or mountain areas) <br />None -- Unknown <br />resent <br />vcrage Annual Precipitation (inches) <br />KXXXXX <br /><10 9 10-25 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 Unknown <br />resent <br />lnique site features: Recharge area, coarse soil, nearby wells. <br />XXXXx <br />/Z At least <br />None `� one <br />ore than <br />one <br />COLUMN TOTALS» >TOTAL POINTS <br />✓ C.J <br />* + <br />ample Result: IS T OR E) <br />RANGE OF TOTAL POINTS <br />48 pt—4-7fpts or <br />9 pts or moret.3.3 <br />MAXIMUM ALLOWABLE O -T -X -E LEVELS (PPM) <br />1 50 <br />50 <br />50 <br />1NA\3 <br />amp a RcpLt; <br />�= 35 �r�.TPH <br />ASOLINE <br />AXIMUM ALLOWABLE TPH LEVELS (PPM) <br />IE <br />1000 0 10 <br />SEL <br />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 LOT 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 RECOMMENDATION/CONCLUSION <br />1. Are BTX 8 E or TPH Concentrations > Allowable Levels YesX o <br />2. Recommend Site Closure es I o I X If Yes, Refer to Site Mitigation for Evaluation <br />VII, REVIEW EVALUATION • TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />CONCUR WITH STAFF <br />RECOMMENDATION FOR CLOSURE <br />ES <br />0 <br />EFERRED TO SITE MITIGATION FOR <br />EVALUATION <br />ES <br />0 <br />ATE REFERRED <br />/ / <br />ATE CLOSURE LETTER MAILED <br />AME OF <br />LH eJ 11U (UGTWKSHT)\5/90 v <br />EH 29 80 <br />