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SAN JOAQUI,A TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL H. 'H DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> NAME OF FACILITY h R15 ' th WEEPS CODE ��p <br /> DDRESS �. as,h �y TANK 1D # <br /> TANK SIZE U (� UEL TYPESDe <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # acility Status Code oc.Soil/GW Cont 1Yes Jo <br /> Number of Tanks at facility Nge of Tanks(if available) IType of Tank IStee) Fbrgl ngl Dual <br /> 111. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o if yes, give dates) <br /> as a repair made to the tank system) IYes No 1 11f yes, what Was repaired) <br /> ns repair done under inspection? es o ere soil samples analyzed? es to TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill mknown110 <br /> ther: <br /> IV. 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/Year Iq Y�6 verage Annual Precipitation = 4 10 25 <br /> Dn-Site Well(s) <br /> es IN o umber & Type Irr am ub <br /> S Score S Score S Score <br /> istance to Welts) from Tank ft; ft; ft 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet)'W­+,D- 30' >100 1-100 S7 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) 10 None Unknown 3resent <br /> average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> Df leachate (i.e., septic systems, water wells, ponds) C 0 None Unknown resent <br /> )nique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxffx--�fix None one one <br /> COLUMN TOTALS»>TOTAL POINTS V + $ + <br /> ample Result: (8 STP X OR E) .130 RANGE OF TOTAL POINTS 9 pts or more 41 48 pts__7 40 pts or Less <br /> �3o fn"n' <br /> _r r B T X E B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> 'ample Result: GASOLINE 1000 100 10 <br /> n AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> JJ-V IESEL 10,000 1000 100 <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 Lem d- <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels tkff <br /> Jo -7 q.01 <br /> / 1 <br /> 2. Recommend Site Closure 1Y <br /> es o If Yes, Refer to Site Mitigation for Evaluation <br /> .���� <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR t'l r&tlo � <br /> -ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES 0 EFERRED TO SITE MITIGATION FOR EVALUATION EY 10 r nI <br /> r <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />