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SAN JOAOUIN-uWNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEn0H DIVISION q <br /> 1. UGST WORKSHEET FOR SITE CLOStRE EVALUATION ATE ! t <br /> AHE OF FACILITY SWEEPS CODE f Z:�JC <br /> DDRESSO s, TANK ID # Z <br /> TANK SIZE ODD A UEL TYPE (�,,,� LQAt <br /> It, GENERAL SITE HISTORY <br /> Is permit current? es1 . o ermit # cility Status Code �j oc.Soil/GW Contes o <br /> umber of Tanks at facility ge of Tanks(if available) a,3 ,.j ype of Tank teel rgt ngl al <br /> 111. TANK HISTORY WMMAitd ( W O <br /> as Tank tested? es a acted precision test ? es0 If yes, give date s) //'fW <br /> as a repair made to the tank system? IYes No f yes, what was repaired? <br /> ins repair done under inspection? es o ere sail samples analyzed? es o TXEPN-G H-0 b/EDB <br /> ype of failure/discharge atastrophic Eong-term leakage ve fill ,known ther: <br /> 1V. 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/Yc r '� verage Annual Precipitation = 4 10-25 <br /> �o lqs <br /> ite�(S) o umber 8 Type Irr om ub <br /> S care S core S core <br /> istance to Welts) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 if 0 if 0 f <br /> R condition R condition R ondition <br /> V. Site feature - Leaching Potential Analysis E is met E is met E s met <br /> inirrium Depth to groundwater from the.Soil Sample (feet) >100 1-100 Q 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) b None Unknown DIresent <br /> vcrage Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> nn-Made conduits which increase vertical migration r <br /> f teachate (i.e., septic systems, water wells, ponds) None Unknown :J Present <br /> lnique site features: Recharge area, coarse soil, nearby wells. At teasti lore than <br /> xxxxx None one one <br /> COLUMN. TOTALS»>TOTAL POINTS 10 + 1B + <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINT 9 pts or more 41 - 48 pts 40 pis or less <br /> �afyi5�1g9 G ppir , , F15 <br /> Ix E 8 T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM 50 50 .3 .3 1. 1. NA\3 <br /> "ample Result: ASOLIN 1000 100 10 <br /> �DQhAXIMUM ALLOWABLE TPH LEVELS„(PPM)'1 TPH 1ESEL 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the teaching potential <br /> analysis. (i.e., site is currently on UGT ontamination List for Boit or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., sc2e_0 points'. If depth <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for 8TX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure iYes o If Yes, Refer to Site Mitigation for Evaluation <br /> Vtl. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/ ENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES 0 EF.ERRED TO SITE MITIGATION FOR EVALUATION fES 0 <br /> ATE REFERRED 23 / ATE CLOSURE LETTER MAILED / ! <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />