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i I <br /> IOWAVe �- <br /> SAW JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION a <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE I ���— l 0 <br /> AME OF FACILITY WEEPS CODE <br /> DRESS ANK ID # 3 9-� <br /> ANK SIZE UEL TYPE C''L <br /> 11. GENERAL SITE HIST <br /> Is permit current? eso ermit # - /acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) IType of Tank ISteel brgl ngl I Dual <br /> 111. TANK HISTORY <br /> Jas Tank testedT es o ailed precision test ? es o If yes, give date(s) F <br /> Jas a repair made to the tank system? es No 11f yes, what was repaired? <br /> Jas repair done under inspection? es o ere soil samples analyzed7 es o TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfill noun ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water b of/Year verage Annual Precipitation k= 4 0-25 <br /> -Site Wells) es 1 110 umber & Type If rr am ub <br /> S Score S Score S Score <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Saaple (feet) /()I >100 1-100 15 25-5O1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown PIresent <br /> verage Annual Precipitation (inches) xxxx <10 9 10-25 xxxxxxx 26-4012 <br /> Ian-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. Q At least 4ore than <br /> xxxx None ( one one <br /> COLUMN TOTALS»>TOTAL POINTS O + (/�� + 5 zzv <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> g,y,y T�sA -E7=A;L <br /> X' j .O — ��7 3 MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) B1 1 50 1 50 1 50 .3 .3 X E NA13 <br /> ample Result- SOLINE 1000 100 10 <br /> A % A.A d O IMUM ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> OOTNOTES: ***If documented soil and/or ground water contamination is present, do not o piete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> k1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> 12 if precipitation is > 40 inches, score 0 points. <br /> 13 Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION r 11 <br /> 1. Are BTX & E or TPH Concentrations > Allo le Levels Yes o <br /> 2. Recommend Site Closure es o !f Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION fES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />