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SAN JOAOUIN 5NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE, DIVISION ATE <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> 1. <br /> WEEPS CODE <br /> AME Of FACILITY � <br /> ANK IO # , <br /> DDRESSI <br /> ARK SIZE "i f j UEL TYPE ' <br /> !I. GENERAL SITE HISTORY <br /> ermit a <br /> ac ` f�it Status Code oc. it/GW Cont es <br /> Is permit current? es o o <br /> umber of Tanks at facility <br /> ge of Tanks(if available) N YPe of Tank Leel Fbrgl ngl. Dual <br /> IIf. TANK HISTORY <br /> as Tank tested? es o ailed precision test 7 es a " If yes, <br /> as a repair made to the tank system? es No e f yes, what was repaired7 <br /> as repair done under inspection? es a ere soil samples analyzed? e o TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfilt nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INS P CTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water of/Year j�, ;� verage Annual Precipitation = 4 0-25 <br /> -Site Welk(s) es o umber & Type Irr om ub <br /> S core 5 core S core <br /> 0 is C pts C pts <br /> istance to Well(s) from Tank "'�5- ft. ft: ft 0 if P O if O f <br /> R -ondition R ondition R ondition <br /> Site Feature - Leaching Potential Analysis <br /> E is met E is met E "s met <br /> inimum Depth to groundwater from the Soil Sample (feet) <br /> >100 1-100 z5-5oL1 <br /> ractures in subsurface (applies to foothills or mountain areas) <br /> None 17 Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxx 26-40L <br /> an-Made conduits which increase vertical migration None Unknown resent <br /> f leachate (i.e., septic systems, water wells, ponds) <br /> At least lore than <br /> nique site features: Recharge area, coarse sail, nearby welts. xxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + <br /> ample Result: {B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> 7 XE <br /> 1— 9 L MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM] s 50 SO 50 .3 .3 1. 1. NAL <br /> ASOLINE 1000 100 10 <br /> ample Result: <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) DIESEL 100 <br /> p TPH 10,000 1000 <br /> OOTNOTES: ***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 /> L if precipitation is > 40 inches, score 0 points. <br /> L Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> Vi. STAFF RECOMMENDATION/CONCLUSION [s"^� i <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure es a If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONLUR WITH STAFF RECOMMENDATION FOR CLOSURE E5 O EFERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> ATE REFERRED �F / / ' ' ATE CLOSURE LETTER MAILED <br /> G <br /> LMEFTOR <br /> EH 23 80 (UGTWKSHT)\5/90 ✓f` <br />