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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> 1• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY �- <br /> � ��� :� 7 WEEPS CODE � y 3 ,1 <br /> DRESS <br /> TANK SIZE UEL TYPE <br /> 11. GENERAL SITE HISTORY <br /> Is permit current7 es o ermit # - acility Status Code oc-Soil/GWCant es o <br /> umber of Tanks at facility Be of I ks(if available) IType of Tank tee( Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested] es f o IFailed precision test 7 es o If yes, give date(s) <br /> as a repair made to the tank system? Yes No f yes, what was repaired? <br /> as repair time under inspection] es o ere soil samples analyzed? es o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage vertill noun cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Sainp Les Received es o epth to Ground water et/Year verage Annual Precipitation = 4 0-25 <br /> -Site Well(s) es I iIo umber 8 Type Irr an ub <br /> S core S I Score S 3core <br /> istance to Wells) from Tank ft; ft; _ ft C 0 pts C 9 pts C 5 pts <br /> O if 0 if 0 if <br /> Site Feature - Leaching Potential AnR onditim R condition R onditionalysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 51-100 25-50L <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxx 26-40L <br /> Ian-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 we one <br /> COLUMN TOTALS»>TOTAL POINTS . r <br /> ample Result: (B T % OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B T X E BT I % E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA <br /> 13 <br /> ample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> DOiNOTES: "=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 COntamina 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 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 TPH Concentrations > plLowable Levels Yes o <br /> �2. Recommend Site Closure lr es I �!o I If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE <br /> II COMPLETED BY A SUPERVISOR/SENIOR <br /> CONCUR 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 /> EH 23 80 (UGTWKSHT)\5/90 <br />