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SAN JOAQU, NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL ` ;H DIVISION <br />I, UST WORKSHEET FOR SITE CLOSURE EVALUATION DATE <br />AME OF FACILITY ECORD ID <br />OGRESS ANK ID # <br />TANK SIZE UEL TYPE <br />11. GENERAL SITE HISTORY <br />ermit current? es I/ o ermit lFacility Status Code oc.Soil/GW Cont es I o <br />er of Tanks at facility ge of Tank(if available) ype of•Tank 13teel I Fbrgl I ngl Dual <br />III. TANK HISTORY <br />as Tank tested? <br />es <br />I V/'�o <br />o <br />I <br />ailed precision test ? <br />es <br />o <br />"'-If <br />yes, give date(s) <br />4 <br />as a repair made to the tank system? Yes No 11f yes, what was repaired? <br />on -Site Well(S) <br />as repair done under inspection? <br />es o ere soil samples analyzed? <br />es <br />umber & Type <br />o <br />Irr <br />TXE <br />om <br />PH -G <br />ub <br />PH -D <br />core <br />10 pts <br />if <br />condition <br />is met <br />b/EDB <br />ype of failure/discharge <br />S <br />C <br />0 <br />R <br />E <br />atastrophic long-term leakage <br />istance to Well(s) from Tank <br />verfill <br />R <br />mown <br />then: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received <br />es <br />I V/'�o <br />I <br />epth to Ground Water <br />14'5+f/Year <br />verage Annual Precipitation <br />= <br />4 <br />0-25 <br />on -Site Well(S) <br />es <br />o <br />umber & Type <br />Irr <br />I <br />om <br />I <br />ub <br />S <br />core <br />10 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />9 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />5 pts <br />if <br />ondition <br />is met <br />istance to Well(s) from Tank <br />ft; ft; ft C <br />0 <br />R <br />Site Feature - Leaching Potential Analysis E <br />inimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />1-100 <br />25-5011 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />None <br />9 <br />Unknown <br />resent <br />verage Annual Precipitation (inches) xxxxxx <br /><10 <br />9 <br />10-25 <br />Kxxxxxx <br />26-40\22 <br />an -Made conduits which increase vertical migration <br />f leachate (i.e., septic systems, water wells, ponds) <br />None <br />�f <br />( <br />Unknown <br />3resent <br />pique site features: Recharge area, coarse soil, or wells. <br />(Muncipal=>2000 ft; domestic=>500 ft; irr/agricultural=present] xxxx <br />None <br />1 <br />At least <br />one <br />ore than <br />one <br />COLUMN TOTALS>>>TOTAL POINTS <br />Q <br />y 1 <br />Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more <br />8T X E <br />s ) ® Co 5j MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) 1 50 50 50 <br />41 - 48 pts <br />40 pts or less <br />B <br />.3 <br />T <br />1.3 <br />X <br />1.' <br />E <br />1. <br />NA�3 <br />Sample Result: SOLINE 1000 <br />AXIMUM ALLOWABLE TPH LEVELS (PPM) <br />TPH IESEL 10,000 <br />100 - <br />10 <br />1000 <br />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 />j2 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 LevelsYes 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/LEAD SENIOR <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE VES EFERRED TO SITE MITIGATION FOR EVALUATION fES 0 <br />ATE REFERRED F <br />ATE CLOSURE LETTER MAILED <br />F <br />OF <br />UATOR <br />EH 23 80 (UGTWKSHT)\5/94 <br />