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SAN JOACUIN Cv . f PUBLIC HEALTH SERVICES/eyvlRaaMENTHEA:.. . Dtvtsta ATE <br /> UGST WCRKSHEET FoR SITE CLOSURE EVALUATICN <br /> EPS CODE 5) <br /> OF fACILtTT �/ <br /> / 7ANK IO � ///v <br /> ✓ 4 <br /> SIZE ` 5Q - TYPE �1 <br /> HERAL SITE HISTORY <br /> rmit currentt es o ermit a ' <br /> aeility Status Cade oc.Soii/GW Cont es o <br /> I <br /> -r of Tanks at facility I ge of Tanks(if available) y'j, voe of Tank feel hrgt ngl Dual <br /> ANK HISTCRY <br /> Tank tested? es o <br /> ailed precision test ? es o If yes, give <br /> what was repaired? <br /> a repair made to the tank system? es No f yes' o TXE PH-G PH-0 b/08 I <br /> repair done under inspection7 es <br /> o ere soil samples analyzed? es <br /> of failure/discharge atascrophic Long-term Leakage <br /> verfill awn they: <br /> VAL HISTORY (ATTACK INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Oma/ � verage Annual Precipitation 4 0-ZS <br /> L Samples Received es <br /> o epth to Ground tracer 6 of/Year O'& i <br /> Irr cm <br /> Site uell(s) es o umber b Type S core S core S core <br /> C 0 pts C pts C pts <br /> ' C I� ft; ft O if a f j <br /> tante to well(s) from Tank ft; I S L• 0 f a di cion <br /> onditicn R andition R <br /> r w c 's met E is met E 's met <br /> Site feature - Leaching Potential Analysis 25-50\1 <br /> 14-0imum Depth to groundwater from the Soil Sample <feet) — >100 <br /> 1-100 <br /> None Unkna►n resent <br /> ctures in subsurface (applies to foothills or mountain areas) x=x 26-40\2 <br /> xxxxxX <10 I 9 10-25 ; <br /> rage Annual Precipitation Cinches) <br /> -Made conduits which increase vertical migration None Unknown bresent <br /> Leachate (i.e., septic systems, water wells, ponds) <br /> are than <br /> At feast <br /> ,ue site features: Recharge area, coarse soil, nearby wells. Kxxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS <br /> 40 is or Less <br /> le Result- (B T X DR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts P <br /> 1% ti '/IJ Q,. 8 T X E B T X E <br /> NA\3 <br /> r1lt tf�- WU MAXI" ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1_ 1. <br /> OLIHE 1000 100 1 10 <br /> le Result/ �t�d IMUM ALLOWABLE TPH LEVELS (PPM) <br /> 10,000 � 1000 t0O <br /> PH r <br /> Che teaching potential <br /> E <br /> THOTS: "'If documented soil and/or gro++�d water contamination is present, do not <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground voter.) <br /> \1 If depth is > 5 ft. and < 25 ft., scare 0 points. If depth <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXSE are not applicable at a TPH concentratio0n of 10 ppm (gasoline) or tO0 ppm (diesel). <br /> STAFF RECCMENDATION/CCNCLUSION <br /> Are BTX S. E or TPH Concentrations > Allowable Levels les o <br /> Recommend Site Closure lyes o If Yes, Refer to Site Hitigatien for Evaluation <br /> REVIEIW EVALUATION - TO BE CCMPLETED By A SUPERVISOR/SENIOR <br /> 1 <br /> EFERRED TO SITE HITIGATICH FOR EVALUATION ES a <br /> ONCUR WITH STAFF RECCMMENDATION FOR CLOSURE YES I ! <br /> t <br /> ATE REFERRED / 3J -/, ATE CLOSURE LETTER MAILEDIAME OF <br /> VALUATOR L� <br /> H 23 80 (UGTVKSHT)\5/90 <br />