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ANE OF FACILITY <br />DORESS <br />[AUK StZE U <br />If. GENERAL SITE HISTORY <br />Is permit current? es <br />umber of Tanks at facility <br />Ili. TANK HISTORY <br />SAN .IOAOUIN CA PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAL T9V <br />ISION <br />UGST WORKSHEET FOR SITE CLOSURE EVALUATICH DATE <br />i 30 EPS CODE <br />A /` ANK ID if <br />TYPE <br />t 0- acitity Status Code oc.Soit/GW Cont es <br />9e of Tanks(if available) ype of Tank teel I brgl ngl I Dual <br />as Tank tested? <br />es <br />IN01 <br />oailed <br />precis)ln test 7 <br />es <br />of/Year <br />o1 <br />if <br />yes, give date /` s) <br />/ <br />as a repair made to the tank system? Yes U,No 11f yes, what was repaired? <br />-7AVP 440 <br />as repair done wider inspection? <br />eso <br />ere soil samples analyzed? <br />es <br />o <br />T E <br />I <br />PH -G <br />PH•0 <br />ub <br />b/EOS <br />ype of failure/discharge <br />atastrophic <br />long-term leakage <br />verfill <br />nknown 1 <br />10cher: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />oit Samples Received <br />es I <br />IN01 <br />0 <br />epth to Ground Nater <br />ES <br />of/Year <br />;Average <br />Arnuat Precipitation <br />ATE REFERRED <br />/ / <br />ATE CLOSURE LETTER MAILED <br />-Site Wells) <br />es <br />LAME OF <br />:VALUATOR <br />o <br />umber & Type <br />Irr <br />I <br />om <br />I <br />ub <br />S <br />Score <br />10 pts <br />S <br />C <br />Score S <br />9 pts C <br />core <br />5 pts <br />istance to Wells) from Tank <br />ft; ft; ft C <br />0 <br />if <br />ondition <br />is met <br />0 <br />R <br />E <br />if 0 <br />condition R <br />is met E <br />f <br />ondition <br />s met <br />R <br />i. Site Feature - Leaching Potential Analysis E <br />inimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />1-100 <br />25-50\1 <br />ractures in subsurface (applies to foothills or mountain areas) <br />None <br />Unknown <br />Dresent <br />Average Annual Precipitation (inches) xxxxxx <br /><10 <br />9 <br />10-25 xxxxxxx <br />26-40\2 <br />an -Made conduits which increase vertical migration <br />f leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />resent <br />pique site features: Recharge area, coarse soil, nearby welts. <br />At least <br />4ore than <br />xxxx <br />None <br />one <br />one <br />COLUMN TOTALS»>TOTAL POINTS <br />+ <br />+ <br />Sample Result: (B T X OR E) <br />RANGE OF TOTAL POINTS P pts or more <br />41 <br />48 pts 40 pts or less <br />B <br />T <br />XTE8 <br />X E <br />MAXIMLH ALLOWABLE B -T -X -E LEVELS (PPM) 1 <br />505.3 <br />1 <br />JT <br />.3 <br />1. 1. NA\3 <br />Sample Result:ASOLINE <br />1000 <br />100 10 <br />AXIMUM ALLOWABLE TPH LEVELS (PPM) <br />10,000 <br />1000 100 <br />TPH <br />31ESEL <br />OOTNOTES: "'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 > 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 BTX&E are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />V1. STAFF RECCHMENDATION/CONCLUSION <br />1. Are BTX &.E or TPH Concentrations > Allowable Levels Yes o <br />2. Recomnend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO BE CCMPLETED BY A SUPERVISOR/SENIOR <br />CONCUR WITH STAFF RECCMMENDATION FOR CLOSURE <br />ESIN <br />0 <br />EFERRED TO SITE MITIGATION FOR EVALUATION <br />ES <br />0 <br />ATE REFERRED <br />/ / <br />ATE CLOSURE LETTER MAILED <br />' y <br />LAME OF <br />:VALUATOR <br />EH 23 80 (UGTWKSHT)\5/900 4P <br />