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SAN JOAQUINCOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL ,.,STH DIVISION <br /> L UGST WORKSHEET FOR SITE CLOSURE EVALUATION 1 AfE <br /> AME OF FACILITY WQ$�Qt/�,� �t( .c. 1.,t _¢1_ _ WEEPS CODE <br /> DRESS IT ANK ID # <br /> TANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> rt <br /> Is permit current? es o ermit # - acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility 1 -1__ ge of Tanks(if available) 1,ype of Tank teel Fbrgl ngL I Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested? es o 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 repaired? <br /> as repair done under inspection? as o ere soil samples analyzed? as o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-tern Leakage verfitL nknown I lother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received as o epth to Ground Water 3j of/Year SGV ;; verage Annual Precipitation k= 4 0-25 <br /> n-Site Well(s) es o umber 8 Type Irr om ub <br /> S Score S Score S Score <br /> istance to WeLL(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ordition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> ini mum Depth to groundwater from the Soil Sample (feet) >100 1-100 5 25-5011 <br /> Fractures in subsurface (applies to foothills or mountain areas) 1(J None I Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx -10 9 10-25 xxxxxx 26-40L <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown j resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At Least ore than <br /> xxxx None ( me one <br /> COLUMN TOTALS»>TOTAL POINTS + t`-� <br /> ampLe�Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> L)N I f YrlMAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 3 1. 1. NAL <br /> Sample Result: ASOLINE 1000 100 10 <br /> ppn��^ AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> N n ( TPH IESEL 1 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 /> L If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> L If precipitation is > 40 inches, score 0 points. <br /> L 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 SIX 8 E or TPH Concentrations > Allowable Levels Yes o L --I-- , <br /> 2. Recommend Site Closure as o If Yes, Refer to Site Mitigation for Evaluation P/�- <br /> VI 1. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR 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 J ! \LLA G' `-�- � ✓ <br /> EH 23 80 (UGTWKSHT)\5/90 <br />