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SAN JOAOUIM"COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL 1 ALTH DIVISION <br /> i <br /> 1, UGST WORKSHEET FOR SITE CLOSURE EVALUATION RTE �/ Z <br /> AME OF FACILITYGa d / / EEPS CODE <br /> DDRESS �� 'ivANK ID/# -r <br /> TANK SIZE UEL TYPE <br /> 11. GENERAL SITE HIST Pd� <br /> 1s permit current? es 0 ermit # cility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) IType of Tank ISteel Fbrgl I Isn9i Dual <br /> Ill. TANK HISTORY <br /> Was Tank tested? es I To ailed precision test ? Ls o If yes, give date(s) II/ <br /> as a repair made to the tank system? es Na f yes, what was repaired? 1 aa <br /> as repair done under inspection? es o ere soil samples analyzed? es le I TXE PN-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage I 1Dverfitt nknown ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> i <br /> oil Samples Received es I INe epth to Ground Water of/Ye r INverage Arcual Precipitation = 4 10-25 <br /> Sit�Wett(s) o umber & Type Err om ub <br /> S core S core S core <br /> istance to We(t(s) from Tank ft; ft; ft C 0 pts C pts C pts <br /> 0 'f 0 if 0 f <br /> R ondition R condition R ondition <br /> . Site Feature - Leaching Potential Analysis E 's met E is met E s met . <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1.100 Q 25-50\1 <br /> ractures in subsurface (applies to foothitls or mountain areas) (O None Unknown 3resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 Jxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> i leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> lnique site features: Recharge area, coarse soil, nearby wells; At least ore than <br /> xxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS + + T <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINT 9 pts or more 41 - 48 pts 40 pts or Less <br /> B T X E B JT JXJE <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM 1 50 50 50 .3 .3 1- 1. NA\3 <br /> -ample Result: 2ASOONI 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 teaching potential <br /> analysis. (i.e., site is currently on UGT ontamination List for soil or ground water,) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth i=5 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 cont ntration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1, Are BTX & E or TPH Concentrations > Allowable Levels Yes IN <br /> o <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br /> Vtl. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR j <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)\5/90 <br /> Ex 29 80 <br />