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SAN JOAQUICOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> 1, UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY Uhl WEEPS CODE <br /> DDRESS ` e ANK ID # <br /> TANK SIZE loo UEL TYPE <br /> IT. GENERAL SITE ISTOR <br /> Is permit current? es o ermit # I lFacitity Status Code oc.Soit/GW Cont as F <br /> o <br /> umber of Tanks at facility Be of Tanks(if available) ype of Tank IS <br /> teal Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es I a ailed precision test 7 es o If yes, give date($) <br /> as a repair made to the tank system? as No f yes, what Was repaired7 <br /> ns repair done under inspection? es I qo ere soil samples analyzed? Ifes to I TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage 5verfilt nknown 1 10ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .oil Samples Received <br /> as o epth to Ground Nater �p of/Year ; � verage Annual Precipitation = 4 10-25 <br /> )n-Site Welt(s) as X o umber & Type Irr I om ub <br /> S core S Score S Score <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R onditi on R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) d None Unknown resent <br /> versge Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26-40\2 <br /> nn-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, Water wells, ponds) None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS t ' 3 <br /> ay�m1ple Result: (D T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts pts or les <br /> I v aj CC B T X E B T X <br /> FMALE B- <br /> XIMUM ALLOWABLE LEVELS (PPM) 1 50 50 50 .3 .3 1. NA\3 <br /> 'ample Result: ( p-\ AXIMU14 ALLOWABLE TPH LEVELS (PPM) ASOLTNE 1000 100 10 <br /> 1�`` I <br /> Iv� � `T H IESEL 10,000 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leachl entiel <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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Arc BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure as o If Yes, Refer to Site Mitigation for Evaluation <br /> Vil, REVIEW EVALUATION . TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES C 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 />