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SAN JOAQUIWNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL *TH DIVISION <br />I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br />AME OF FACILITY WEEPS CODE <br />DDRESS 6 - TANK ID # <br />TANK SIZE I f Z, 000 (_IIFUEL TYPE I,/ 7c< <br />** <br />permit current? ks o Nermit # - acility Status Code On ID oc.Soil/GW Cont es o <br />fiber of Tanks at facility ge of Tanks(if available) ype of Tank tee Fbrgl I ngl Dual <br />111. TANK HISTORY <br />as Tank tested? <br />es <br />I <br />INOIX <br />I <br />ailed precision test ? <br />es <br />of/Year <br />o <br />• If <br />yes, give dates) <br />4 <br />as a repair made to the tank system? Yes No x <br />Itf yes, what was repaired? <br />es <br />as repair done under inspection? <br />es o <br />ere soil samples analyzed? <br />es <br />o <br />TXE <br />PN -G <br />PH -D <br />b/EDB <br />ype of failure/discharge <br />atastrophic <br />long-term leakage <br />verfill <br />nknown <br />ther: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Soil Samples Received <br />es <br />I Y�o <br />I <br />epth to Ground Water <br />i <br />of/Year <br />0 <br />verage Annual Precipitation <br />= <br />4 <br />0 25 <br />n -Site Wells) <br />es <br />o <br />AME OF <br />:VALUATOR <br />umber & Type <br />Irr <br />am <br />ub <br />S <br />C <br />0 <br />R <br />Score <br />10 pts <br />if <br />condition <br />S <br />C <br />0 <br />R <br />Score <br />9 pts <br />if <br />condition <br />S <br />C <br />0 <br />R <br />3core <br />5 pts <br />if <br />condition <br />istance to Well(S) from Tank <br />ft; ft; - ft <br />V. Site Feature - Leaching Potential Analysis <br />E <br />is met <br />E <br />is met <br />E <br />is met <br />inimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />1-100 <br />5 <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />None <br />0% <br />Unknown <br />resent <br />Average Annual Precipitation (inches) <br />KXXXXX <br /><10 <br />9 <br />10-25 <br />Kxxxxxx <br />26-40\2 <br />an -Made conduits which increase vertical migration <br />f leachate (i.e., septic systems, water welts, ponds) <br />None <br />Unknown <br />resent <br />pique site features: Recharge area, coarse soil, nearby wells. <br />xxxx <br />None <br />Cl <br />At least <br />one <br />lore than <br />one <br />COLUMN TOTALS>>>TOTAL POINTS <br />+ <br />'36 <br />+ <br />° <br />L•) ` <br />Sample Res��u��lt . (B T X OR E <br />�- It (►"'�YK, E- W{ p <br />T¢ i Ira 1� <br />)(= 366.0 <br />RANGE OF TOTAL POINTS <br />9 pts or more <br />41 - <br />48 pts <br />40 pts or less <br />MAXIMUM ALLOWABLE B -T -X -E LEVELS (PPM) <br />B <br />1 <br />1 T XE <br />50 50 50 <br />B T <br />.3 .3 <br />X <br />1. <br />E <br />1. <br />NA\3 <br />Sample Result: <br />ASOLINE <br />1000 <br />100 <br />10 <br />TPH <br />AXIMUM ALLOWABLE TPH LEVELS (PPM) <br />IESEL <br />10,000 <br />1000 <br />100 <br />---- <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 > 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 TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />VI. STAFF RECOMMENDATION/CONCLUSION /kk,' YV Vn(rT--.iZ: fv.,41 ,-' r evc,1v4 of <br />1. Are BTX & E or TPH Concentrations > Allowable Levels -Yes FT <br />r" <br />2. Recommend Site Closure es o �- If Yes, Refer to Site Mitigation for Evaluation <br />VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br />ONCUR WITH STAFF RECOMMENDATION <br />FOR CLOSURE <br />fES <br />0 <br />EFERRED TO SITE MITIGATION FOR EVALUATION <br />fES1 <br />0 <br />ATE REFERRED <br />/ // / <br />�/ <br />ATE CLOSURE LETTER MAILED <br />AME OF <br />:VALUATOR <br />EH 23 80 (UGTWKSHT)\5 <br />