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SAN JOAQUIN QLTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HAFd DIVISION <br /> 1•r - UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE Q <br /> AME OF FACILITY � SWEEPS CODE EJ <br /> DORESS `jTANK ID pl <br /> AHK SIZE I UEL TYPE <br /> II. GENERAL SITE HISTO Y <br /> ww <br /> Is permit current? es o ermit N acitity Status Code oc.Soit/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) IType of Tank ISteel Fbrgl I ngl I Dual; <br /> [It. TANK HISTORY <br /> Jas Tank tested? as o ailed precision test ? es' o If yes, give dates) <br /> Jas a repair made to the tank system? IYes No 1 11f yes, what was repaired? <br /> ms repair done under inspection? es o ere soil samples analyzed? es Jo TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfilL nknown ther: <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 of/Yearr verage Annual Precipitation = 4 10-25 <br /> Site Wett(s) IYes I X o umber & Type Irr am ub <br /> S Score S Score 5 Score <br /> istance to Welt(s) from Tank ft; ft; ft C 10 pts C 9 pts C i pts i <br /> - 'O if 0 if 0 if I <br /> R ondition R condition R ondition <br /> . Site Feature - Leaching Potential Analysis Em is met E is met E is met . <br /> inimum Depth to groundwater from the Soil Sample (feet) 4 r 2,100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> I <br /> verage Annuat Precipitation (inches) KXXXXX <10 9 10-25 Kxxxxxx 26-40\2 <br /> An-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) None Unknown S resent <br /> - I <br /> Inique site features: Recharge area, coarse soil, nearby wells; At least C ore than ; <br /> xxxx None one ,._J one <br /> ' COLUMN TOTALS»>TOTAL P01HT5 <br /> Sample Result: (S T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> N <br /> Cut .a-QD /r' 0 TX E 8 T X E <br /> 11 MAXIMUM ALLOWABLE 0-T•X•E LEVELS (PPM) 1 56 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS.(PPM) <br /> ^TPH IESEL 10,000 1000 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 2, 5 ft. and c 25 ft., score 0 points'. If depth <25 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not applicable at a TPH concentration of 10 ppn (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations 2, Allowable Levels Yes INo <br /> Ye <br /> 2. Recommend Site Closure es o If s, Refer to Site Mitigation for Evaluation <br /> Vit. REVIEW EVALUATION - TO BE CC14PLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0, EFERRED TO SITE MITIGATION FOR EVALUATION rSI 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VRLUATOR <br /> EH 23 SO (UGTWKSHT)\5/90 <br /> EH 29 80 <br />