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A9116 Amik <br /> SAN JOAQUIN 'TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEi „ DIVISION <br /> I. UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE � <br /> AME OF FACILITY I �y 6 lue, RECORD ID <br /> DORESSTANK ID # - <br /> TANK SIZE UEL TYPE <br /> II. GENERAL SITE HISTORY <br /> Is permit current7 es o ermit #Eget <br /> - acility Status Code oc.Soil/GW Cont es o <br /> Number of Tanks at facility Tank(if available) 1.30 IType of Tank IsteeL Fbrgl ngl Dual <br /> III. TANK HISTORY <br /> Was Tank tested? es o ailed precision test ? es o If yes, give date(s) <br /> :tas a repair made to the tank system? es No f yes, what was repaired? <br /> as repair done under inspection? es No ere soil samples analyzed7 es o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verfi[l nown they: <br /> !V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oit Samples Received es I IN01 epth to Ground Water I a6lof/Year verage Annual Precipitation <br /> n-Site WeIL(S) es o under & Type Irr om ub <br /> S Score S Score S core <br /> is:anca to Well s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 'f 0 if 0 'f <br /> R ondition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 I 25-501 <br /> 1Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> "e rage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40 ,2 <br /> an-Made conduits which increase vertical migration <br /> f Leachate (i.e., septic systems, water welts, ponds) None Unknown Dresent <br /> Unique site features: Recharge area, coarse soil, or wells. At least 4ore than <br /> (Muncipat=>2000 ft; domestic=>500 ft; irr/agricut tura l=present) xxxxxx None one one <br /> COLUMN TOTALS»)TOTAL POINTS I + + <br /> sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or Less <br /> B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA13 <br /> ;j <br /> mple Resu SOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> kOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the Leaching potential <br /> e 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 /> \3 Levels for BTX&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 Yes o ® �� <br /> 2. Recommend Site Closure es No <br /> If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES EFERRED TO SITE MITIGATION FOR EVALUATION fES I INO <br /> ATE REFERRED I / / ATE CLOSURE LETTER MAILED <br /> 4AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />