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SAN JOAQU?W COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL"MLTH DIVISION <br /> I' UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY j,/ ,z 1 t .� �1 y,L n WEEPS CODE �Da3 <br /> DDRESS d `r+' •.�� 1 /MALf4 A'K YLIIG (� l:Al'V� ANK ID # <br /> ANK SIZE 'bcc <br /> If GENERAL SITE HISTORY <br /> Is permit current? es o ermit # Kr Y acility Status Code r...l' ' oc.Soit/GW Cont es o <br /> umber of Tanks at facility t ge of Tanks(if avaitable) VRK ype of Tank tee( Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> 'as Tank tested? es oailed precision Test es o If yes, give date(s) <br /> as a repair made to the tank system? as No f yes, what was repaired? <br /> ns repair done under inspection? es o ere soil samples analyzed? esJo TXE H-G PH-D b/EDB <br /> IType of failure/discharge atastrophic tong-term leakage verfill mknown [her: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .oil Samples Received es o epth [o Ground Water t of/Year s verage Annual Precipitation R= 114 10-25 <br /> -Site Wells) es o xumber 8 Type Irr M ub <br /> S core S Score S 3core <br /> istance to Welt(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if O if <br /> R ondition R conditi on R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet)lig-10n D >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f Leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> ample Result: D T % OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> 15 p p f'F'1 G I T % E B T % E <br /> 1 1 MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> 'ample Result: 4)e5011r Q- ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> J <br /> 40f2faffi TPH IESEL 1 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 /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION HConcentra <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> I2. Recommend Site Closure �'es I [Jo I If Yes, Refer to Site Mitigati at for Evaluation <br /> `JI1. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FCLOSURE "ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES JO <br /> OR <br /> )ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> Ex 29 80 <br />