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Y SAN JOAOUTA COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTALLTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> i AME OF FACILITYWEEPS CODE j�,3 / <br /> DRESS I ! TANK ID # 3q -,�36 3--b <br /> ANK SIZE 1 a �jQ O )FUEL TYPE .9 eL(/FLYI��GC� <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # - acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility kge of Tanks(if available) �� ype 'of Tank Leel IFbrgl I 1SnaL I Dual <br /> III. TANK HISTORY <br /> Jas Tank tested? es o ailed precision test ? es o If yes, give date(s) <br /> Jas a repair made to the tank system? IYes No f yes, what was repaired? <br /> as repair done under inspection? es o ere soil samples analyzed? 'es 0 TXE PH-G PH-D b/EDO <br /> l ype of failure/discharge atastrophic long-term Leakage verfill nown then: <br /> IV. REMOVAL HISTORY (ATTACH INSP CTION REPORT FOR SITE DETAILS/COLLECT DATA FOR{LEACHIHG POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Nater �6 0 of/Year ,; verage Arcual Precipitation <br /> -Site Wells) es o <br /> af <br /> Type Irr omub5 core i S core S core <br /> istance to Wett(s) from Tankt; ft; ft C 0 pts ' C pts C pts <br /> o if I 0 if o if <br /> R ondition R condition R ondition <br /> 1. Site Feature - Leaching Potential Analysis 6 is met' E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 'I 1-100 25-50L } <br />� L } <br /> ractures in subsurface (applies to foothills or mountain areas) None � Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26-40L <br /> Ian-Made conduits which increase vertical migration <br /> f Leachate (i.e., septic systems, water wells, ponds) None a Unknown resent <br /> nique site features: Recharge area, coarse soil, nearby wells. At least are than <br /> iKxxxxx None.:, one one <br /> COLUMN TOTALS>>>TOTAL POINTS + ;p 3 + s <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 4 is or more"' 41 - 48 is 40 is or Less <br /> P P P <br /> ND <br /> B T X E e T <br /> E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS PPM 1 50 50 50 <br /> ( ) .3 .3 1K. 1. NAL <br /> ample Results: SOLINE 1000 100 10 <br /> 1AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> D TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not comptece the leaching potential <br /> anatysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> Ll If depth is > 5 ft. and s 25 ft., score 0 points. If depth ­5 ft., do not use table. <br /> ,L2 If precipitation is > 40 inches, score 0 points. ;` i _ <br /> ,L3 Levels for 8TX&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 Concentratioos > Allowable Level sYes o 11 <br /> 2. Recommend Site Closure es4 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 fES1 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED it / / <br /> VALUATQR , <br /> EH 23 80 (UGTWKSHT)\5/90 i } <br />