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SAN JOAQUIN W PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL. DIVYSYOk <br /> 1. UST WORKSHEET FOR SITE CLOSURE EVALUATION ATE ( ! Z?— <br /> AME OF FACILITYI r ECORD ID j76 f <br /> DRESS I ANK ID : i <br /> TANK SIZE61JEI TYPE <br /> [I. GENERAL SITE HISTORY <br /> UCont e <br /> s permit current? es o ermit T - acility Status Code oc.Soil/GW s I o <br /> Number of Tanks at facility ge of Tank(if available) '30Type of Tank teal ( Fbrgl ngl Dual <br /> Iti. TANK HISTORY 5` <br /> Was Tank tested? fres fVo ailed precision test ? es o ( If yes, give dates) <br /> �-as a repair made to the tank system? es I No f yes, what was repaired? r" lc. a a r <br /> ,as repair done under inspection? as �aere soil samples analyzed7 es o TXE I PH-G PH-0 b/EDB <br /> Type of failure/discharge tastrophicl long-tern leakage TTverfill ther: <br /> V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received fes o Iepth to Ground Water 11ef/Year verage Annual Precipitation k= 4 0-25 <br /> Site Well(s) Yes ( fo (umber & Type IrrI an ub <br /> S Score S Score S core <br /> stance to WetL(s) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 i f 0 if 0 f <br /> R onditicn R condition R ondition <br /> �. Site Feature - Leaching Potential Analysis E is met is met Z s met <br /> Minimum Depth to groundwater from the Soil Sample (feet) I >100 i 1-100 ( 25-50\1 <br /> IFrac:ures in subsurface (applies to foothills or mountain areas) + None I Unknown I resent <br /> Average Annual Precipitation (inches) xxxxxx 00 9 ! 10-25 xxx 26-4012 <br /> II an-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknown ' resent <br /> Unique site features: Recharge area, coarse soil, or wells. I At Least More than <br /> i (M,xcipal=>2000 ft; domestic-->500 ft; irr/agricut tura l=present] None ate I one <br /> COLUMN TOTALS»>tOTAI POINTS - <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more ( 41 - 4$ pts i 40 pts or Less <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) a 50 150 50 .3 I. <br /> $amole Result: OLIVE 1000 100 10 <br /> IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH rlSEL 10,000 1000 100 <br /> FCOTNOTES: * 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 /> \33, Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> i <br /> VI. 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 l� <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/LEAD SENIOR <br /> CHCUR WITH STAFF RECOMMENDATION FOR CLOSURE IES �VO EFERRED TO SITE MITIGATION FOR EVALUATION ES ( 0 <br /> AT. REFERRED I / / BATE CLOSURE LETTER MAILED <br /> 1 <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/94 <br />