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SAN JOACUIN +NTY PUBLIC HEALTH SERVICESANVIRONMENTAL Hr _;A DIVISION !O <br /> +I, `UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> nME OF FACILETY Q .� EPS GOOF <br /> ORES$ l TANK ID 0 27t-1 <br /> TANK SIZE GLJ UEL TYPE I <br /> i <br /> 11. GENERAL SITE HISTO Y .* <br /> 1s 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 teet brgl ngt Dual <br /> III. TANK HISTORY <br /> 'as Tank tested? es o I lFaiLed precision test ? es o If yes, give date(s) <br /> Jas a repair made to the tank system? es No 11f yes, what was repaired? <br /> ,1s repair done under inspection? es o ere soft samples analyzed? IYes I Io TXE IT <br /> PH-G PH-D b/ED0 <br /> ypo of failure/discharge atastrophic Eong-term leakage ver fill known 1 10then. <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es o I epth to Ground hater of/Year ! (Q; verage Annual Precipitation <br /> -Site Wells) es o umber 8 Type Irr em <br /> S Score S Score S core <br /> istance to Wett(s) from Tank ft; ft; ft C 10 pts C 9 pts C pts <br /> 0 if 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 Sail Sample (feet) 51-15=� >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) Kxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wed s, ponds) None Unknown —5 resent <br /> inique site features: Recharge area, coarse soil, nearby wells. At leastore than <br /> }}xxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS 1 + + <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or Less <br /> B I T X E B =TX EMAXIMUM ALLOWABLE 0-T-X-E LEVELS (PPM} 1 50 50 50 .31. NA\3 <br /> Sample Result: ASOLTNE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> /✓�TPH IESEL. 10,000 1000 100 <br /> DOTNOTES: "•Rif 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 <n5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Arc BTX 8 E or TPN Concentrations > Allowable Levels Yes o <br /> I <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES =E <br /> FERRED TO SITE MITIGATION FOR EVALUATION LES I 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> ' I <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />