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SAN JOAOUIN -"..FITY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTF. DIVISION q <br /> • UGST WORKSHEET FOR SITE CLOSURE/EVALUATION ATE _-,I- 'T_9 <br /> AME OF FACILITY -L' y ��QL�-�- �l-C-e"t�- WEEPS CODE <br /> DRESS [ ,? e ' (V. JZ ANK ID # - 0 <br /> TANK SIZE 50 (fQ Ra_ UEL TYPE <br /> 11. GENERAL SITE HISTORY <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 Tank teel FbrgL ngl Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested? es 1H. 1 <br /> ailed precision test 7 es o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired7 <br /> as repair done under inspection? es o ere soil samples analyzed7 es o T%E PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term Leakage verfill known cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o epth to Ground Water 9 of/Year �j , S� verage Annual Precipitation = 4 0-25 <br /> n-Site WeLI(s) IT <br /> as o umber 8 Type Irr M ub <br /> S Score S Score S Score <br /> istance to Well(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R onditIm R cond ition R ondition <br /> W. Site Feature - Leaching Potential Analysis E is met E is met E is WE <br /> inimun Depth to groundwater from the Soil Sample (feet) G_ s o -100 1-100 25-5 1 <br /> Fractures in subsurface (applies to foothi Lls or mountain areas) None Unknown resent <br /> Average Annual Precipitation (inches) xxxx <10 9 10-25 xxxx 26-40L <br /> an-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water we(ls, ponds) None Unknown resent <br /> nigle site features: Recharge area, coarse soil, nearby welts. At Least ore than <br /> xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + <br /> ample Result:y(e T R E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> T % E e T % E <br /> j' MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NAi <br /> ample Result: ''''Jy�1vv�� ASOLINE 1000 100 10 <br /> , / 5� T/T IMUM ALLOWABLE TPH LEVELS (PPM) PSEL 10,000 1000 100 <br /> FOOTNOTES: ...if documented soil and/or ground water contamination is present, do not complete the Leaching pot entiaL <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 /> \3 Levels for STXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION ' <br /> 1. Are BTX 8 E or TPM Concentrations > Allowable Levels Yes o <br /> 2. Recon nd Site Closure IYes <br /> 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 ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\590 <br />