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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL xEALTH DIVISION <br /> I- UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE p� <br /> AME OF FACILITY /� �,. WEEPS CODE ! ,�3 <br /> ADDRESS a��\S- �/ r [TANK ID # I JL l! 3 — 0 ) <br /> ANK SIZE I UEL TYPE <br /> II. GENERAL SITE H S RY <br /> Is permit current? es o ermit # acility Status CodeI IDoc.Soi l/GW Cont es o <br /> umber of Tanks at facility / ge of Tanks(if available) ype of Tank IStee[ Fbrgl I ISngl Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? IT <br /> es o If yes, give date(s) <br /> as a repair made to the tank system? 1Yas No f yes, What Was repaired7 <br /> ns repair time under inspection? es No ere soil samples analyzed? as Jo I TXE ✓ PH-r ✓ PH-D I DB. <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS COLLECT DATA LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received as oepth to Ground Water r of/Year verage Annual Precipitation = 4 10-25 <br /> -Site Wells) es o umber 8 Type Irr / om I ub <br /> S core S Score 5 Score <br /> istance to Well(s) from Tank 1/S9 ft; ft; ft - C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R conditl on R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimun Depth to groundwater from the Soil Sample (feet) —(o�L= 3/ >100 1-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) /O None Unknown resent <br /> verage Annual Precipitation (inches) Kxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> an•Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) / None Unknown zl� resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At Least Tore than <br /> xxxxx None one �one <br /> COLUMN TOTALS>>>TOTAL POINTS Z <br /> ample Result: SB T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 is or le <br /> 6s7>°/ ( <br /> ZZ 0 T X E B T X E <br /> TY1 MAXIMUM ALLOWABLE 0•T-%-E LEVELS (PPM) 1 50 50 50 .3 .3 X t. NA\3 <br /> -ample Result: 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 lea to l <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, scare 0 points. <br /> \3 Levels for 8TX8E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION /OL <br /> t, Are 8T% 8 E or TPH Concentrations > Allowable Levels Yes o <br /> �2. Recommend Site Closure 1,as /o If Yes, Refer to Site Mitigation for Evaluation <br /> VI1. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> -ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 I 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 /> EH 29 80 <br />