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SAN JOAQUIN NTY PUBLIC HEALTH SERVtCES/ENVIRONMENTAL H# DIVISION — <br />I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE t^ <br />AME OF FACILITY OA, <br />WEEPS CODE �►� <br />cry � �i <br />DRESS <br />TANK ID # <br />8 Y 5o jo S <br />TANK SIZE 15001 UEL TYPE <br />11 <br />ENERAL SITE n1,!VR1 ** <br />permit current? es o /ermit # - acility Status Code oc.Soil/GW Cont es o <br />ber of Tanks at facility ge of Tanks(if available) j ype of Tank teel Fbrgt ngl Duat <br />III TANK HISTORY <br />Jas Tank tested? <br />eso <br />100 <br />ailed precision test ? <br />es <br />o <br />if <br />yes, give dates) <br />Jas a repair made to the tank system? es No <br />f yes, what was repaired? <br />S <br />Jas repair done un1. der inspection? <br />es o <br />ere soil samples analyzed? <br />as <br />i pts <br />if <br />o <br />condition <br />TXE <br />ondition <br />PH -G <br />is met <br />PH -D <br />b/EDB <br />>100 <br />inimum Depth to from the Soil Sample (feet) ->Q- <br />Ly -pe of failure/discharge <br />atastrophic <br />long-term leakage <br />verfitt <br />known <br />Unknown <br />ther: <br />IV.REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DEIAILS/VVLLtW unin rvn LG....-- �..•.-•• - •-••••-•---- <br />Soil Samples Received <br />es <br />100 <br />epth to Ground Water 5 <br />of/Year <br />verage Annual Precipitation <br />n-Sil lumber & Type irr ub S core S <br />Score <br />S <br />Score <br />istance to Well(S) from Tank ft; ft; ft C 10 pts C <br />if 0 <br />9 pts <br />if <br />C <br />0 <br />i pts <br />if <br />0 <br />R condition R <br />condition <br />R <br />ondition <br />Site Feature - Leaching Potential Analysis E is meet E <br />is met <br />E <br />is met <br />>100 <br />inimum Depth to from the Soil Sample (feet) ->Q- <br />1-100 <br />25-501 <br />groundwater <br />Fractures in subsurface (applies to foothills or mountain areas) None <br />Unknown <br />resent <br />verage Annual Precipitation (inches) xxxxxx <10 9 <br />10-25 <br />Kxxxxxx <br />26-40L <br />an -Made conduits which increase vertical migration <br />f leachate (i.e., septic systems, water wells, ponds) A None <br />Unknown <br />resent <br />pique site features: Recharge area, coarse soil, nearby wells. <br />17 <br />At least <br />one <br />ore than <br />one <br />xxxxx None <br />COLUMN TOTALS>>>TOTAL POINTS ,(� + 7 <br />+ <br />ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts <br />40 pts or less <br />B T X E BIT X E <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 50 .3 1. 1. <br />NAL3 <br />Sample Result:A1 bz.iP� ASOLINE 1000 100 <br />'� TPH LEVELS (PPM) <br />10 <br />100 <br />pc° yel AXIMUM ALLOWABLE <br />IESEL 10,000 1000 <br />5 /®C� TPH, <br />QOTNOTES: ***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 />k1 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 BTM&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX & E or TPN Concentrations > Allowable Levels �YesT r o <br />2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION <br />ATE REFERRED / / ATE CLQSURE LETTER MAILED <br />AME OF <br />VALUATOR <br />EH 23 80 (UGTWKSHT)\5/90 <br />