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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY SWEEPS CODE 1 <br /> ESS ��.ls � jvTANK ID a <br /> AHK SIZE UEL TYPE <br /> fI GENERAL SITE HISTORY cno Py.. <br /> is permit current? es o ermit N lFacitity Status Code oc.SoitJGW Cont es o <br /> weber of Tanks at facility kge of Tanks(if available) ype of Tank teel Fbrgl 1 15. <br /> ngl Dual <br /> III TANK HISTORY � � C.,,% �� ,IUB. 31.1`q 1-?� <br /> 'as Tank tested?les a ailed precision test ? es I IHOI If yes, give date(s) <br /> as a repair made to the tank system? 1Yes No f yes, what was repaired? <br /> i►s repair done under inspection? es mol ere soil samples analyzed? es ►o TXE PH-G PH-D b/EDD <br /> ype of failure/discharge atastrophic long-term took age verf►tl nknown 1 10cher <br /> IV REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water L6 of/Year 19 3& verage Annual Precip►tatlon = 4 10-25 <br /> n-Site Wells) IYes o umber & Type Irr om I tub <br /> 5 Score 5 Score 5 Score <br /> istance to Welts) from Tank ft; ft; ft C 10 pts C 9 pts Cpts <br /> 0 f 0 if 0 f <br /> R ondition R condition R and►tion <br /> Site Feature - Leeching Potential Analysis E is met E is met E s met <br /> inirrun Depth to groundwater from the Soit Sample (feet) >100 1-100 25-50\1 <br /> ctures in subsurface (applies to foothills or mountain areas) C None Unknown resent <br /> rage Annual Precipitation (inches) KXAXXX <10 9 10-25 Axxxxxx 25-40\2 <br /> an-Made conduits which increase vertical migration <br /> Df leachate (I.e , septic systems, water wells, ponds) None Unknown >resent <br /> Inique site faatures: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxx Nona one one <br /> COLUMN TOTALS»>TOTAL POINTS 177. G 3 -7 <br /> Sample Result: (B T X OR E) - RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T X E <br /> �eheyri r ra`-ff P iy� MAXIMIi ALLOWABLE D-T•X-E LEVELS (PAM) 1 ISO 50 50 3 3 1. 1 NA\3 <br /> "amiplV Result: ASOLINE 100q 10.0 10 <br /> AXIFAJ14 ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <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 /> \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 /> Z Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel) <br /> 11 STAFF RECOMMENDATION/CONCLUSION <br /> 1, Are BTX & E or TPH Concentrations > Allowable Levels has x FE <br /> 2 Recommend Site Closure 1Yes I lio X If Yes, Refer to Site Mitigation for Evaluation <br /> 11 EV1EW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> CUR WITH STAFF RECOMMENDATION FOR CLOSURE ES ±111 <br /> €FERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> ATE REFERRED / / ATI: CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />