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SAN JOAOUIN CCL)W(YY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALAIdIVISION <br /> 1, UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> AME OF FACILITY rj IbG.�K L EPS CODE <br /> DDRE SS �� '�' �r vVA 1 ANK 10 N <br /> ANK SIZE UEL TYPE <br /> II. GENERAL SITE HISTORY :. <br /> Is permit current? ea o ermit a acili ty Statw Code oc.Soil/GW Cant as o <br /> umber of Tanks at facility Be of tanks(if available) yPe of Tank [eel brgl rgl Dwl <br /> 111. TANK HISTORY <br /> Jas Tank tested? es I o alled precision test ? as o If yes, give daze(s) <br /> Jas a repair made to the tank system? es No f yes, what was repaired? <br /> ms repair done under inspection? es o ere soil samples analyzed? as Io T%E PH-G PH•D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill —n 1 10ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es I o epth to Ground water I of/Year verage Annual Precipitation = 4 10-25 <br /> -Site Well(s) es I 0 tmher 8 Type I Irr I lIpm ub <br /> S Score Scare <br /> S core <br /> istance to Wells) from Tank ft; ft; ft C 0 Pts C Pts C pts <br /> 0 if 0 if 0 f <br /> R ondi tion R ondit ion R ordition <br /> Site Feature - Leaching Potential Analysis E is met E is met E 's met <br /> inimum Depth to grourdwater from the Soil Sample (feet) �(� >100 1.100 25-50\1 <br /> racturea in subsurface (applies to foothills or mountain areas) None Unknown Present <br /> versge AIrXlaL Precipitation (inches) Xxx <10 9 10-25 xxxxxx 26-40%2 <br /> nn-Haft conduits which increase vertical migration �1 <br /> f leachate (i.e., septic systems, water wells, ponds) �U None Unknown Present <br /> Inipue site features: Recharge area, coarse soil, nearby wells. At least are than <br /> xxxx None 9 one one <br /> COLUMN TOTALS»>TOTAL POINTS ! /� • - -J <br /> ample Result: IS T % OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> Y 27-70Yn'i B T % E 0 % E <br /> MAXIMUM ALLOWABLE 0-T•X-E LEVELS (PPM) i � 50 50 50 .3 .3 1. NA\3 <br /> -ample Result: SOLINE 1000 100 10 <br /> [MUM ALLOWABLE TPH LEVELS (PPM) <br /> / TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ***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 /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth 4=5 ft., do not use table. <br /> \2 If precipitati an is > 40 inches, score 0 points. <br /> \3 Levels for BTXSE are not applicable at a TPH concentration of 10 ppn (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION / <br /> t, Are BTX 8 E or TPN Concentrations > Allowable Levels Yes o <br /> I2. Recommend Si ca Closure Yes o I Itlf Yes, Refer to Site Mitigation for Eval motion <br /> V11. REVIEW EVALUATION - TO BE CCHPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VALUATOR /SyJ <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> ZH 29 80 <br />