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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA'C H DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATIONIon IqQ <br /> ATE <br /> AME OF FACILITY M - � WEEPS CODE <br /> DRESS 2 ST. ANK ID # - Q1 . <br /> AHK SIZE UEL TYPE -RER:�r, <br /> 11. GENERAL SITE HISTORY <br /> .rw <br /> Is permit current? eso ermit # - a iLity Status Code q� oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) Or ype of Tank toel Fbrgl ngI Dual <br /> 111: TANK HISTORY <br /> Jas Tank tested? es o ailed precision test ? as o If yes, give dates) <br /> as a repair made to the tank system? es No I A yes, what wasrepaired? <br /> as repair done under inspection? es o ere sail samples ana yzed? as o TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic Long-term leakage ver ill nown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAI OLLECT D TA F H TENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water of/Yea a erage Annual Precipitation k= 4 0-25 <br /> w <br /> -Site WeLL(s) es o umber & Type Irr as ub <br />.. S core 5 Score S Score <br /> istance to Welt(s) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 0 if 0 f <br /> R ondition R condition R ondition <br /> 1. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feel) >100 1-700 5 25-50x1 <br /> ractures in subsurface (applies to foothills or mountain areas) None q Unknown Iresent <br /> verage Arnuat Precipitation (inches) x <10 9 10-25 xxxxxxx 25-40L <br /> an-Made conduits which increase vertical migration <br /> 1 <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown „)' resent i <br /> nique site features: Recharge area, coarse Boit, nearby wells. 9 At least 4ore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + Z4• + } a 3-7- <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T X E <br /> $ l.Z�rz•Z,1(�1.5 �-2 14AXIMLJMI ALLOWABLE B-T-X-E LEVELS (PPM} 1 50 5D J50 .3 .3 1. 1. NA1 <br /> ample Result: GASOLINE 1000 100 10 <br /> 14 IMLIM ALLOWABLE TPH LEVELS (PPM) <br /> TPH I£SEL 10,000 1000 100 <br /> i <br /> FOOTNOTES: ***If documented soil and/or ground water contaminati n is present, do not complete the leaching potential i <br /> analysis. (i.e., site is currently on UGT C tamination List for soil or ground water.) <br /> L if depth is > 5 ft. and < 25 ft., score 0 points. f depth <=5 ft., do not use table. <br /> 12, If precipitation is > 40 inches, score 0 points. <br /> •L3 Levels for BTX&E are not appticable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> Vt. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPM Concentrations > Allowable Levels Yes <br /> 2. Recommend Site Closure es o if Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR NIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE E 0 EF£RRED 10 SITE MITIGATION FOR EVALUATION V1S 0 <br /> ATE REFERRED 9 / /0 / /� ATE CLOSURE LETTER MAILD / / <br /> AME OF ` <br /> VALUATOR <br /> EH 23 80 (UGTWKS tA5190 4 <br />