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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 7 <br /> AME OF FACILITY CODE / Y 3 y <br /> DD RESS - ANK <br /> Sc.cro <br /> (ANK SIZE Ude UEL TYPE .c_ �Pc, <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # - eciLity Status Code 5-/ oc.Soi l/GW Cont es r !o <br /> Nonber of Tanks at facility) ge of Tanks(if available) ype of Tank teeL Fbrgt Dual <br /> III. TANK HISTORY <br /> as Tank tested? es iFailed precision test ? es o If yes, give date(s) <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 ITXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill known ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Sunples Received es o epth to Ground Water of/Year verage AmuaL Precipitation = 4 0-25 <br /> -Site well(s) es o umber 8 Type Irr on ub <br /> S core S Score S core <br /> istance to WeIL(S) from Tank ft; ft; . _ ft C 0 pts C 9 pts C - pts <br /> 0 if 0 if 0 if <br /> R odition R odition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is Piet <br /> ininxxn Depth to groundwater from the Soil Sairple (feet) -100 1-100 25-50L <br /> Fractures in subsurface (applies to foothills or mountailn areas) None Unknown resent <br /> %verage Annual Precipitation (inches) xxxxx 00 9 10-25 KXXXXXX 26-40L <br /> an-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 least ore than <br /> xxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS . r <br /> 'ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or nore 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. NA13 <br /> -apple Result: ASOLINE 1000 1pp 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> DUTNOTES: *"If docuu&nted soil and/or ground water contamination is present, do not coPplete the leaching potential <br /> analysis. (i.e., site is currently on UGT ContuRinwa tion List for soil or ground water.) <br /> L If depth is > 5 ft. 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 BTXSE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPM Concentrations > Allowable levels Yes o 'I <br /> I2. Reccenend Site Closure FeS I No I �If Yes, Refer to Site Mitigation for Evaluati MI <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES O 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 />