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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> E OF FACILITY WEEPS CODE --R-3 3 <br />++ DRESS / ! ANK ID # 36, O <br /> ANK SIZE 1a �©� uE! TYPE If <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es o IV ermit # - acility Status Code oc.Soil/GW Cont es a <br /> umber of Tanks at facility ge of Tanks0 f available) ngl Dual <br /> ype orf Tank teal Fbrgl <br /> II1. TANK HISTORY �# <br /> Jas Tank tested? eso ailed precision test 1 es o If yes, gine dates) <br /> Jas a repair made to the tank system? es No f yes, what was repaired? <br /> .r <br /> Jos repair done under inspection? es 40 ere sail samples analyzed? es 0 TXE PH-GPH-D b/EDS <br /> Type of failure/discharge atastrophic tong-term leakage verfill nownh they: <br /> IV. REMOVAL HISTORY (ATTACH INSP TION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Receivedes o epth to Ground Water 1/60of/Year ; verage Annual Precipitation <br /> -Site WOLL(S) es o umber & Type Irr om ub <br /> S Score S Score S core <br /> )i stance to Wetl(s) from Tank 1.5—Lf t' ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 if <br /> R 'ondition R condition R ondition <br /> v. ' <br /> Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50L <br /> Fractures in subsurface (applies to foothills or mountain areas) 'None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxx 26-40-2 <br /> Ian-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water welts, ponds) None � Unknown � resent <br /> nique site features: Recharge area, coarse snit, nearby wetts. f At least 4ore than <br /> xxxx :None ] one, one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 4 pts or more, 41 - 48 pts' 40 pts or less <br /> I V O u' la B TX E B JT X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 150 50;1 .3 .3 1. 1. NAL <br /> Sample Result: SOLINE 1000 100 10 <br /> A)!� a)QSa,i IMU14 ALLOWABLE TPH LEVELS (PPM) <br /> IV %&4-1 <br /> H IESEL '10,000 1000 100 <br /> OOTNOTES: ***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 depthl<=5 ft:, do not use table. <br /> L If precipitation is > 40 inches, score 0 points. 'I <br /> i Levels for BTX&E are not applicable at a TPH concentration�of 10 'ppm (gasotine) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentratio�p > Allowable Levels Yes o <br />` 2. Recomnend Site Closure es- o If Yes, Refer to Site Mitigationl,fo=Eva�Luadon <br /> VI1. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR �} r <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES 0 EFERRED 7Q SIIE 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 />