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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION ATE o <br /> 1 UGST WORKSHEET FOR SITE CLOSURE EVALUATION 0 -3/- <br /> WEEPS CODE <br /> AME OF FACILITY �P�u �Cc�iv�� / , I- <br /> DDRE SS ARK ID # 39 <br /> TANK SIZE 5-�ej �� UEL TYPE W,5,p <br /> 11. GENERAL SITE HISTORY ++ <br /> Is permit current? es o ennit # - acility Status Code oc.Soil/GW Cant es o r <br /> ember of Tanks at facility ge of Tanks(if available) IType of Tank teel Fbrgl ngl I Dual <br /> 111. TANK HISTORY <br /> Fasa <br /> tested? es o ' ailed precision test 1 es o If yes, give date(s) / <br /> air made to the tank syst em7 es No _ f yes„ what was repairr done under inspection? es o ere soil samples analyzed? es o 3T%E PH-G IPN-D b/EDB77 <br /> ailure/discharge atastrophic long-term leakage verfill nknoun [her: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Sail Samples Received es o epth to Ground Water of/Year verage Annual Precipitation = 11 <br /> 4 0-25 <br /> n-Site Wells) es o umber & Type Irr = ub <br /> S core S Score S 'core <br /> Distance to Well(s) from Tank ft; ft; ft C 10 pts C 9 pts C i pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondition <br /> 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 51-100 25-501 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> Average Annual Precipitation (inches) xxxxxx 00 9 10-25 xxxxxxx 26.40E <br /> Man-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At leas[ lore than <br /> xxxxx None one one <br /> COLUMN TOTALS» TOTAL POINTS + + <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 40 pts 40 pts or less <br /> R I T X E D T X E <br /> MAXIMUM ALLOWABLE B-T•X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA1 <br /> Sample Result: ASOLINE 1000 100 10 <br /> IN AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPN IESEL 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 /> \1 If depth is > 5 ft. and x 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. Are BTX & E or TPM Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluatim <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR 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 <br /> FH 23 80 (UGTWKSHT)\5/90 <br />