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:3 SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALIH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY 14 � � EEPS CODE <br /> DDRESS `� C� ��� TANK ID # <br /> TANK SIZE (d O UEL TYPE <br /> It. GENERAL SITE NIST <br /> Is permit current? es o ermit # acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Fank feel Fbrgl I ngl I Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es a ailed precision test ? es o 1f yes, give date(s) <br /> as a repair made to the tank system? es. No 11f yes, what was repaired? <br /> +s repair done under inspection? esoFL. <br /> ere soil samples analyzed? es Io TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic g-term leakageverfill I nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es 15qo epth to Ground Water Aof/Year verage Annual Precipitation = 4 10.25 <br /> Dri-Site Weil(s) es o umber & Type Irr om ub <br /> S Score S Score S Score <br /> istance to Welt(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E 's met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) (k(j-ice` >100 - 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown �Iresent <br /> verage Annual Precipitation (inches) xxxxx <10 9 10-25 Kxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) None ri Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxxfxxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS V + OX <br /> Simple Result: (B T OR E) RANGE OF TOTAL POINTS 9 pts or more 43 pts o <br /> 7(= .1031 Y =•D` B T X E B MAXIMUM ALLOWABLE B-T-X-f LEVELS (PPM) 1 50 50 50 .3 .3NA\3amp a RGA lt: ASOLINE 1000010 <br /> f ,�•�-- AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 2?,5d(�rTPH IESEL 10,000 ( 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leachrng potential <br /> analysis. (i.e., site is currently an 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 BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1, Are BTX & E or TPH Concentrations > Allowable Levels Yes ^ o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE C014PLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES 0 EFERRED TO SITE .MITIGATION FOR EVALUATION ES D <br /> AT£ REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF 1 <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br /> M - <br />