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HEAL,rl DIVISION <br /> SAN JOAQUINOCLjTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL <br /> VALUATION ATE _2 <br /> I UGST WORKSHEET FOR SITE CLOSURE <br /> DEEPS CODE 1$17 <br /> vo <br /> TANK ID >Y �' —G <br /> pcJ UEL TYPE <br /> I1. GENERAL SITE HISTORY <br /> Is permit current? es 0 ermit a <br /> _ acility Status Code oc.Soil/GW Cont es o <br /> lu.nber of Tanks at facility g <br /> e of Tanks(if available) ype of Tank teel Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested7 es o ailed precision test ? es o If yes, give dates) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es o ere soil samples analyzed? es o TXE PH G PH-D b1ED8 <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown Cher: <br /> 1V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water of/Year , <br /> verage Annual Precipitation = 4 0-25 <br /> n-Site Well(s) es o umber 8 Type Irr om ub <br /> S core S core S core <br /> ft; I ft C 0 pts C pts C pts <br /> istance to Well(s) from Tank ft: 0 if 0 if 0 f <br /> R ondition R ondition R ondition <br /> Site Feature - Leaching Potential Analysis <br /> E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample tfeet) <br /> >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) <br /> None Unknown resent <br /> verage Arin Precipitation (inches) xxxxx <10 9 10-25 xxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration None Unknown resent <br /> f leachate (i.e., septic systems, water wells, ponds) <br /> At least ore than <br /> )nique site features: Recharge area, coarse soil, nearby wells. one one <br /> )cxxxxx None <br /> ff . <br /> COLUMN TOTALS>>>TOTAL POINTS O <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS +9 pts or more 41 48 pts 40 pts or less <br /> Fp— g,- - B T X E B T X E <br /> [a MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> ample Result: <br /> ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) 100 <br /> TPH IESEL 10,000 1000 <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 <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> Vt. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8, E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site gation for Evaluation <br /> VII. REVIEW EVALUATION TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> �ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> )ATE REFERRED Z�/ ATE CLOSURE LETTER MAILED <br /> IAME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90` <br />