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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ilATE Z <br /> / AME OF FACILITY I SWEEPS CODE <br /> DRESS I S17 5, Maw TANK 1D II <br /> (AHK S12E rQ 000 UEL TYPE <br /> ll. GENERAL SITE HISTORY <br /> Is permit current7 es o ermit M - ac(lity Status Code oc.Soil/GW Cant esP <br /> o <br /> umber of Tanks at facility pe of Tanks(if available) Type of Tank tocl brill Hill <br /> III. TANK HISTORY <br /> ns Tank testedT es o ailed precision test 7 es o if yes, give dates) <br /> Jas a repair made to the tank syste±7tll No f yes, what was repaired? <br /> ns repnir dons urxlcr Inspection? o ere soil samples onaty:ed7 es o ITXE IPH-G PH-D b/EDD <br /> Type of fallure/discharge atastrophlc long-term leokape verfill mown cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Sniples Receivedes NO epth to Ground Water 04 of/Year verage Annual Precipitation ■ 4 0-25 <br /> -Site Wells) es o umber t Type Irr am ub <br /> S core S Score S core <br /> istance to Wells) frac Tank �'/) ft; ft; ft C 0 pts C 9 pts C pts <br /> 0 if 0 of 0 if <br /> R -ondition R condition R ordition <br /> Site Feature - Leaching Potential Analysis E is nzet E is met E is NICE <br /> inill a Depth to prourdwoter from the Soil Sanple (feet) ),100 I 1-100 25-5011 <br /> ractures in subsurface (applies to foothills or mountain areas) 0 None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX 410 9 10-25 xxxxxx 26-4012 <br /> nn-flude conduits which increase vertical migration None Unknown resent e <br /> 1 leachate (i.e., septic systans, water wells, <br /> ponds) At least ore than <br /> ique site features: Recharge area, coarse soil, nearby wells. xxxx None a" one <br /> COLUMN TOTALS <br /> »),TOTAL POINTS <br /> arple Result: (8 T X OR E) <br /> RANGE Of TOTAL POINTS .9 pts or more 41 - 48 pts 40-0ts or less <br /> O T K E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .S 1. 1• NA�3 <br /> ASOLINE 1000 100 10 <br /> aiple Result: <br /> Pr'- L%1MJM ALLOWABLE TPN LEVELS (PPM) IESEL 10,000 1000 <br /> 100 <br /> $`�D PP'�` TPH p it7; ! — <br /> OOINOTES: ***If docuaented soil and/or ground water contnna irwtion is present, do not cary�lete the teaching potential <br /> analysis. (i.e., site Is currently on UGT Contanination List for soil or ground water.) <br /> _1 If depth is > 5 ft. and < 25 ft., score 0 points. It depth <-5 ft., do not use tuble. <br /> .\? If precipitation is > 40 inches, score 0 points. <br /> ,L Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX t E or TPN Concentrations > Allowable Levels Yes o4qI <br /> 2. Recommend Site Closure es o if Yes. Refer to Site Mitigation for Eve tion <br /> ( VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> \ FEf <br /> AFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> �ER / / ATE CLOSURE LETTER MAILED <br /> Ell 2S 110 (UGTWKSHT)\5/90 <br />