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SAN JOAQUIN C TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA DIVISION <br /> I, UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> AME OF FACILITY L Lb 6, 2 WEEPS CODE <br /> DDRESS TANK ID # <br /> TANK SIZE 'Z UEL TYPE <br /> 11. GENERAL SITE H1 ORY <br /> ** <br /> Is permit current? as o ermit # acitity Status Code oc.Soil/GW Cont as 0 <br /> Number of Tanks at facility ge of Tanks(if available) IType of Tank teel Fbrgl I ISngt I Dual <br /> Ill. TANK HISTORY <br /> 'as Tank tested? es I IN01 ailed precision test ? as o If yes, give date(s) <br /> as a repair made to the tank system? as No 11f yes, what was repaired? <br /> as repair done under inspection7 Ifas it <br /> ere soil samptes analyzed? es IoTXE PH-G PH-D b/EDBype of failure/discharge atastrophicong-term leakage verfiIL I 4nknown 14then. <br /> IV, REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Eoit Samples Received If <br /> es p epth to Ground Water of/Year 3 ; verage Annual Precipitation = 4 10 25 <br /> n-Site Wet I(s) es / o umber & Type i0m ub <br /> S Score S Score S Score <br /> istance to Wet l(s) from Tank I IZo ft;4�� C To pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sampte (feet) >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown Dresent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> Df teachate (i.e., septic systems, water welts, ponds) None Unknown Dresent <br /> Inique site featur s: Recharge area, coarse soil, nearby wells. At least lore than <br /> dA' ,k— S W gF 82'�-�!A I xxxxx None 9 one one <br /> COLUMN TOTALS>>>TOTAL POINTS + �7LL� + .4 <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> BT X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> 'ample Result: ASOLINE 1000 100 10 <br /> (y AXIMUII ALLOWABLE TPN LEVELS (PPM) <br /> 7 TPN IESEL 10,000 1000 100 <br /> FOOTNOTES: If documented soil and/or ground water contamination is present, do not complete the leaching potentiat ,. <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. tnj <br /> tit If precipitation is > 40 inches, score 0 points. <br /> \3 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 TPN Concentrations > Allowable Levels as o <br /> 2. RecommendSite Closure es o If Yes, Refer to Site Mitigation for EvaluationU)w✓ 5 <br /> 1I. REVIEW EVALUATION - TO BE C011PLETED BY A SUPERVISOR/SENIOR 0 Z-4 <br /> _C)%b <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YESNO EFERRED TO Si UATION YES 0 <br /> ATE REFERRE `, J ATE CLOSURE LETTER MAI ED <br /> dAME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />