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SAN JOAQUI�NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br />I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br />II. GENERAL SITE HISTORY <br />i Is permit current? esI V1 o it # - acility Status Code oil GW Cont es TkOF <br />�j umber of Tanks at facility -tc=k— of Tanks(if available) of Tank teel fbrgl I kngl I Dual <br />as Tank tested? <br />es <br />I <br />ofled <br />precision test ? <br />as <br />;Foe ' <br />age Annual Precipitation <br />If <br />yes, give date(s) <br />0-25 <br />as a repair made to the tank system? as <br />No <br />f yes, what <br />was repaired? <br />r& Type <br />as repair done under inspection? <br />as o <br />e soil samples <br />analyzed? <br />es <br />ub <br />o <br />TRE <br />PH -G <br />PH -D <br />b/EDB <br />ype of failure/discharge <br />atastrophic <br />long-term leakage <br />verfill <br />nknown <br />Score <br />10 pts <br />if <br />ondition <br />ther: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION PORT FOR SITE DETAILS/CCILL CT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />111 <br />LJ <br />Soil Samples Received <br />es <br />0 <br />epth to Ground Water <br />U e /Year <br />ES <br />age Annual Precipitation <br />k= <br />4 <br />0-25 <br />3n -Site Well(s) <br />as <br />X <br />o I <br />r& Type <br />AME OF <br />VALUATOR <br />Irr <br />I <br />w <br />ub <br />S <br />C <br />0 <br />R <br />Score <br />10 pts <br />if <br />ondition <br />S <br />C <br />0 <br />R <br />Score <br />9 pts <br />if <br />condition <br />S <br />C5 <br />0 <br />R <br />3core <br />pts <br />if <br />ondition <br />istance to Wells) from Tank <br />ft; ft; ft <br />V. Site Feature - Leaching Potential Analysis <br />E <br />is met <br />E <br />is met <br />E <br />is met <br />inimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />G1 <br />51-100 <br />25-50L <br />ractures in subsurface (applies to foothills or mountain areas) <br />None <br />C^' <br />Unknown <br />resent <br />verage Annual Precipitation (inches) <br />KXXXXX <br /><10 <br />9 <br />10-25 <br />xxxxxxx <br />26-40L <br />Ian -Made conduits which increase vertical migration <br />Df leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />,�� <br />resent <br />pique site features: Recharge area, coarse soil, nearby wells. <br />- (� <br />At least <br />4ore than <br />None <br />1 _ <br />one <br />one <br />® COLUMN TOTALS» >TOTAL POINTS <br />ample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS <br />49 pts <br />or more <br />41 - <br />48 pts <br />40 pts or less <br />I <br />'_[X <br />E- <br />B <br />T <br />X <br />E <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />1 <br />50 <br />50 <br />50 <br />.3 <br />.3 <br />1. <br />1. <br />NA1 <br />ample Result: <br />ASOLINE <br />1000 - <br />100 <br />10 <br />14 AXIMUM ALLOWABLE TPH LEVELS (PPM) <br />IESEL <br />10,000 <br />1000 <br />100 <br />r TPH <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 />1 If precipitation is > 40 inches, score 0 points. <br />\33 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 TPH Concentrations > Allowable Levels Yes o <br />2 Recommend Site Closure Fes o If Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE <br />ES <br />0 <br />.EFERRED TO SITE MITIGATION FOR EVALUATION <br />ES <br />0 <br />ATE REFERRED <br />/ / <br />ATE CLOSURE LETTER MAILED <br />AME OF <br />VALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />