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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> 1. UGT 'JORKSHEET FOR SITE CLOSURE EVALUATION DATE <br /> kA Of FACILITY - Sw' _ ) CODE <br /> RESSTANK ID S <br /> K SIZE �S J FUEL TYPE <br /> ll. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit S Facility Status Code Doc.Soil/GW Cant Yes No <br /> INurber of Tanks at facility Age of Tanks(if available) Type of Tank Steel FbrgL Sngl Dual <br /> ILL TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test 7 Yes No If yes, give date(s) <br /> Was a repair made to the tank System? Yes No If yea, what was repaired? <br /> Was repair done under inspection? Yes No Were sail saaples are lysed? Yes No BTXE TPH•G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic long-ten leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground water Ref/Year Average Annual Precipitation A-114 10-25 <br /> On-Site Welt s) Yes No Nutter & Type Irr Dcm Pub <br /> S Scare S Score S Score <br /> Distance to Wells) frac Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> V. Site Feature - Leaching Potential Analysis E is net E is met E is met <br /> Minim Depth to groundwater frac the Soil Sanple (feet) >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> Average Annual Precipitation (inches) rouXxu <10 9 10-25 xxxaxzz 26.40\2 <br /> Man-Made conduits which increase vertical migration <br /> of Leachate (i.e., septic systems, water wells, ponds) Mane Unkmwn Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. At least More than <br /> xxxxzx None one one <br /> COLUMN TOTALS>»TOTAL POINTS I + <br /> Saapis Result; (B T X OR E) RANGE OF TOTAL POINTS 49 pts or acre 41 - 48 pts 40 pts or less <br /> i • 08/," <br /> N �-' or`/" B T X E B T X E <br /> y &I .D .or P"" MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. MA\3 <br /> Saaple Result: GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> '� �pv.• TPH DIESEL 10,000 1000 100 <br /> 'FOOTNOTES: " If documented soil and/or ground water contamination is present, do not coaplete 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 STXSE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMME4DATION/CONCLUSION <br /> 1. Are 3TX 3 E or TPH Concentrations > Allowable Levels I-Yes No <br /> 2. Recommnd Site Closure Yes No If Yea, Refer to Site Mitigation for Evaluation) <br /> VII. REVIEW EVALUATION - TO BE COMPLETED 3Y A SUPERVISOR/SENICR <br /> CONCJR WITH STAFF RECCMMENDATION FOR CLOSURE LYES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH .3 30 (UGTwKSHT)\5/90 /V T w vr <br /> 71E �OZV v <br />