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SAN JOAQUIN 6NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL A DIVISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE - <br /> AME Of FACILITY l (,�� (r. WEEPS CODE lyJ/s <br /> DRESS [ / ��� U//, ��. ANK ID # <br /> TANK SIZE $D SSO,ems. UEL TYPE <br /> Il. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # - acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank teal Fbrgt rgl Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test 7 as o If yes, give date(s) <br /> Jas a repair made to the tank systems IYes No 1 11£ yes, what was repaired7 <br /> Jas repair done under inspection? es To ere soil samples analyzed? es o TXE I PH-G I PH-D I b/EDB <br /> Type of failure/discharge atastrophic long-term Leakage verfiLL nknown they: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received eso epth to Ground Water of/Year �(P verage Annual Precipitation = 4 0-25 <br /> On-Site Wells) eso umber 8 Type Irr om ub <br /> S Score S Score S Score <br /> istance to WeLI(s) from Tank ft; ft; ft C 10 pts C 9 pts C <br /> Pts <br /> 0 if 0 if 0 if <br /> R onditi on R conditi on R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimm Depth to groundwater from the Soil Sample (feet) 9- _ >100 1-100 25-5 1 <br /> Fractures in subsurface (applies to foothills or mountain areas) More Unknown resent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 KMxmx 26-4012 <br /> an-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) None Unknown 3resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At Least 4ore than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + + <br /> am/p�le Result: (B TT4 R E) RANGE Of TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1- 1. NAL <br /> Sample Result: ��npppyy�..^^^--- ASOLINE 1000 100 10 <br /> R./ ; `70?7 IM 1M ALLOWABLE TPN LEVELS (PPM) <br /> 77V1 �TPH IE SEL 1 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 /> L If depth is > 5 £t. 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 TPM concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION , <br /> 1. Are BTX 8 E or TPM Concentrations > Allorrwable Levels Yes r o <br /> I2. Recommend Site Closure?Yes I �o I F>If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SIIUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EM 23 80 (UGTWKSHT)\5 90 <br />