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SAN JOACUIN COUNTYIC HEALTH SERVICES/ENVIRCNMENTAL HEALTH ION ' <br />UGST XSHEET FOR SITE CLOSURE EVALUATICN ATE <br />rAME OF FACILITY 11 � EEPS CODE <br />n00RESS�� Urcilr bpd ANX IO 0ANX SIZE UEL TYPE <br />GENERAL SITE HISTORY <br />as <br />permit current7 es o ermit 9 - acitity Status Code 9g, oc.Soit/GW Cont es o <br />r of Tanks at facility ge of Yanks(if available) ype of Tank Leel brgl ngl Oual <br />TANK HISTCRY <br />,s Tank tested7 es o ailed precision test ? es o tf yes, give date(s) <br /><%as a repair made to the tank system? Ires No 11f yes, what was repaired7 <br />is repair done under inspectioni es 40 ere soil samples analyzed? es o TXE PH -G PH -0 b/EDB <br />ype of failure/discharge atastrophic long-term leakage verfill known 10cher: <br />REMOVAL HISTORY (ATTACH INSPECTION REPORT FCR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />`oit Samples Received es <br />o <br />epth to Ground dater <br />S <br />of/Year <br />cam' ; �;� <br />verage Annuat Precipitation <br />i= <br />4 <br />0-25 <br />n -Site 'Jett(s) <br />es <br />I <br />o <br />umber b Type <br />I <br />trr <br />I <br />c- <br />I <br />ub <br />S <br />core <br />10 pts <br />if <br />onditicn <br />is met <br />S <br />C <br />0 <br />R <br />E <br />Score <br />9 pts <br />if <br />condition <br />is met <br />S <br />C <br />0 <br />R <br />E <br />core <br />pts <br />f <br />ondition <br />s met <br />istance to Welt(s) from Tank <br />ft; ft; + ft C <br />0 <br />R <br />Site Feature - Leaching Potential Analysis E <br />Minimum 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 />resent <br />vcrage Annual Precipitation (inches) xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxxxxx <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 />itnicue site features: Recharge area, coarse soil, nearby wells. <br />xxxx <br />None <br />At least <br />one <br />iore than <br />one <br />COLUMN TOTALS»>TOTAL POINTS <br />+ <br />+ <br />Sampte Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more <br />B T X E <br />MAXIMLH ALLOWABLE B -T -X -E LEVELS (PPM) 1 505050.3 <br />41 - 48 pts <br />40 pts or less <br />B <br />MTX <br />E <br />1. <br />NA\3 <br />3ampte Result: <br />TPH <br />SASOLINS 1000 <br />AXIMUM ALLOWABLE TPH LEVELS (PPM) <br />IESEL f 10,000 <br />100 <br />10 <br />1000 <br />100 <br />^OTHOTES: waif docunented soil and/or ground water contamination is present, do not complete the leaching potentiat <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 BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br />STAFF RECCi•SriENDATION/CCNCLUSION <br />It 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes o <br />2. Recommend Site Closure es o Ef <br />:yes, Refer to Site Mitigation for Evaluation <br />REVIEW EVALUATION - TO BE CCMPLETED BY A SUPERVISOR/SENIOR <br />'ONCUR WITH STAFF RECCMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATICN ES 0 <br />ATE REFERRED / / ATE CLOSURE LETTER MAILED y % <br />1AME OF <br />;VALUATOR <br />EH 23 80 (UGTvxSHT)\5/90 <br />