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y <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> 1. f UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY SWEEPS COOE �5 <br /> %DDRESS j ,f S �J� TANK ID a <br /> ANK SIZE UEL TYPE , PD <br /> 11. GENERAL SITE <br /> HISTORY <br /> 11. <br /> Is permit current? cs o ermit 0 ac uity atus ode oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank tee[ Fbrgl ngl Dual <br /> III. TANK HISTORY '1 <br /> L ' ', <br /> :as Tank tested? es V IN01 ailed precision test ? esI . o If yes, give date(s) <br /> Jas a repair made to the tank systFe4s <br /> es No f yes, what was repaired? <br /> ns repair done under inspection7 No ere soil samples analyzed? es to TXE PH-G PH-O b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill nknown then: <br /> 1V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epeh to Ground Water of/Year 193& verage Annual Precipitation <br /> -Site WeL1(s) IYes a umber & Type Irr om ub <br /> S Score S Score 5 Score <br /> istance to Weti(s) from Tank ft; ft; ft C 10 pts C 9 pts C i 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 Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50\1 ,tom <br /> ractures in subsurface (applies to foothills or mountain areas) IC) None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration 17 <br /> f leachate,(i.e., septic systems, water wells, ponds) None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby welts: At least lore than <br /> xxxxx None ��� one one <br /> a COLUMN TOTALS>>>TOTAL POINTS I0 + a�� + .37 <br /> ampEe Result: (R T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> U B 7 X E BMTX. E <br /> JC.�c� ►`- PPm MAXIML11 ALLOWABLE D-T-X-E LEVELS (PPM) 1505050 .3 1. NA\3 <br /> 'ample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPHLEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTES: ***If documented soft and/or ground water contamination is present, do not complete the teaching 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 depth ­5 ft., do not use table. <br /> \2 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 TPH Concentrations > Allowable Levels Yes x o <br /> 2. Recommend Site Closure es o I X If Yes, Refer to Site Mitigation for Evaluation <br /> Vil. REVIEW EVALUATION TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE 'ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION fES O <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> _VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />