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SAN JOAQW COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL 4LTH DIVISION 1 <br /> I, UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 1 12-, — 2 <br /> z AME OF FACILIITY WEEPS CODE 1 S��jCj <br /> DRESS �3 N tl It — AHK ID # - <br /> ANK S12E UEL TYPE <br /> II. GENERAL SITE HISTORYL- <br /> Is permit current? es o ermit # - acility Status Code oc.Soit/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) [Type of Tank ISLeel Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> as Tank tested-1 es a ailed precision test ? es oIf yes, give dates) / <br /> Jas a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es No ere soil samples analyzed? eso TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic Long-term Leakage verfitt nown I lother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samptes Received es I IN01 epth to Ground Water of/Year verage Annual Precipitation k= 4 0-25 <br /> -Site Welts) es o umber & Type Irr om ub <br /> S Score S Score S core <br /> istance to WeLL(s) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 " if 0 if 0 if <br /> R condition R condition R ondition <br /> V. Site Feature- Leaching Potential Analysis E is.met E is met E is met <br /> inimum Deptl to groundwater from the Soil Sample (feet) >100 1-100 ! 25-50]1 <br /> I: Fractures in 'subsurface (applies to foothills or mountain areas) None Unknown resent <br /> ,I <br /> f verage Annual Precipitation (inches) KXXXXX <10' 9 10-25 KXXXXXX 25-4012 <br /> an-Made conduits which increase vertical migration <br /> Df leachate 0.e., septic systems, water wells, ponds) None �- Unknown Present, <br /> nique site features: Recharge area, coarse soil, nearby wells. w At least 4ore than <br /> xxxx None one one <br /> COLUMN TOTALS—TOTAL POINTS <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> T X E _ B IT X E <br /> MAXIMUM ALLOWABLE B-T-x-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. " HA 3 <br /> L <br /> Sample Result: GASOLINE 1000 100 10 <br /> TPH IMUM ALLOWABLE TPH LEVELS (PPM) IESEL 10,000 1000» 100 <br /> f <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 /> 11 If depth is > 5 ft. and < 25 ft., score O points. If depth 4=5 ft., do not use table. <br /> X2 If precipitation is > 40 inches, score 0 points. <br /> L Levels for BTX&E are not applicable at a TPN 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 <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> i AME Of <br /> "VALUATOR � <br /> EN 23 80 (UGTWKSHT)15/90 <br />