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SAN ,IOACUIN COUNTY PUBLIC HEALTH SERVICES/E.NVIRONMENTAL HEALTH DIVISION <br /> UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> TAME OF FACILITY I j C �ECORD III <br /> AOORESS I �ANK iD ;t I - <br /> �ANK Sit= I MFUEL TYPE <br /> (I. GENERAL SITE HISTORY <br /> 1s pe mI <br /> it current? �es �lo permit T - paciLity Status Code Dec.SoiL/GU Cont Yes I^ �7o <br /> i Numcer of Tanks at facility I I;ge of Tank(if available) I �fype of Tank teeL I IFbrgl I �ngl Dual ) <br /> Iii. TANK 4ISTORY <br /> i <br /> as Tank tested? �es �o I Failed precision test ? fes ! ro ( If yes, give date(s) <br /> Nas a repair made to the tank system? Yes I No �f yes, wnat was repaired? <br /> �as -ecair --one unser inspection? fes �oj ere soil samotes analyzed? IYes �o TXE <br /> hype of iai lure/dischargeI ratastrophic I (long-term leakage I overfill I �aiknarn l ,other. <br /> !V. REMOVAL HISTORY (ATTACH INS?ECTiou REPORT FOR SITE DETAILS L=CT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> �oit Sameles Received fes I �.j �epth to Ground Nater of/Year ) Average Annual Precipitation p= �4 h0-25 <br /> II^'..-Site 'WeIL(s) IYes I �0 I dumber & Type Ilrr I cm I pub I I I <br /> S Lore S Score S care <br /> pistance to WeIL(s) from Tankl ft; ft C I10 pts C pts C pts <br /> 0 0 �i 0 f <br /> R audition R Candi ti on R ondition <br /> V. Si:e Feature - Leaching Potential Analysis s met _ jis met E - met <br /> Minimum Depth to groundwater from :::e Soil Sample (seer) I >100 I �1-100 I I Z-:0\1 <br /> F-ac.ures in suosur ace (applies to foothills or mountain areas) 10 ( None I ( Unknown I resent <br /> average Annual Precipitation (inches). _ xxxx ( <10 I 9 ! 10-25 xxxxxx I25-40\2 <br /> Mart-Made conduits which increase vertical migration vi�� <br /> ci leachate (i.e., septic systems, water wells, ponds) ( None 1 Unknown I Present ' <br /> L'nicue site features: Recharge area, coarse soil, or wells. I ( I IAt least ) lore :man <br /> M;rc i ca t=>2000 f ; d4xmestic=»00 ft, i rr/agri cuL tura L=present; fhczzocz None one I one <br /> COLUMN TOTALS»>TOTAL POINTS I I z— L <br /> 7 76 <br /> Samcte Resutt: (3 T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 Sd pts` I 40 pts or Less <br /> 3T X E 3 T x <br /> MAXIALLOW3"7-X-c LEVELS (PPM) 1 50 50 `50 I .3 i 1. 1. NA\3 <br /> LL <br /> �amole Result: I I <br /> � �1AXIMUM ALLOWABLE TPH LEVELS (PPM) SOLINE 1000 10 <br /> IleYI TPH I PIESEL 10,000 1000 100 <br /> COTNOTES. —i f documented soil and/or ground water contamination is present, do not complete the Leacning ,potential <br /> analysis- (i.e., site is currentty on UGT Contamination List for soil or ground water.) <br /> \1 If depth is > S ft, and < 25 ft., score 0 points- If depth �=5 ft., do not use :able- <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> i <br /> L Levels for 3TX&E are not applicable at a TPH concentration of 10 Fpm (gasoline) or 100 ppm (diesel). <br /> V`.. STAFF RECOMMENDATION/CCNCLUSICN <br /> I 1• <br /> Are 3TX 3 E or TPH Concentrations > Allowable Levels I�Yes I o <br /> i <br /> 2. <br /> Recommend Site Closure es I �o I � If Yes, Refer to Site Mitigation for Evaluation) <br /> VII. REVIEW :VALUATION - TO 3E CUIPLETED 3Y A SUPERVISOR/LEAD SENIOR <br /> i <br /> ONCUR 'WITH STAFF RE-COMMENOATION FOR CLOSURE If ESI rO REFERRED TO SITE MITIGATICN FOR EVALUATION AES <br /> t I <br /> ATE REFERRED I / / 'DATE CLOSURE LETTER MAID I / <br /> i <br /> AME OF <br /> VALUATOR <br /> EH 23 30 (UGTWKSHT)\5/94 <br />