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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br />UGRKSHEET FOR SITE CLOSURE EVALUATION DATE i - 1 -7 S Z <br />1. <br />(( SW EPS CODE <br />NAME OF FACILITY ��- L pr, L' <br />v C'T'f <br />TANK ID # ?iGr - 2 S69 <br />ADDRESS 6111 S• 57z_�)6, X r i7 <br />TANK SIZE UU FUEL TYPE'A/1- <br />It. <br />/ e <br />II. GENERAL SITE HISTORY **" <br />Is permit current? Yes No ermit # - Facility Status LodeMSteel <br />Soil/GW Cont Ye! <br />Age of TanksC if available) Type of TFbrgI Sngl <br />Number of Tanks at facility /I k <br />III. TANK HISTORY <br />Was Tank tested? Yes No -ailed precision test T Yes No If yes, give date(s) <br />Was a repair made to the tank system? Yes No J,� If yes, whet was repaired? <br />Was repair done under inspection? Yes No ere soil samples analyzed? Yes No TXE TPH <br />•G TPH-D <br />Type of failure/discharge catastrophic long-term leakage overfill unknown other: <br />IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br />Yes No epth to Ground Water 70Ref/Year <br />S.�, Average Annual Precipitation f <br />Soil Samples Received <br />b <br />Dual <br />14 110-25 <br />On -Site Well(S) Yes No Number & Type Irr Dom Pu S Score S Score S Score <br />Distance to Well(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br />0 if 0 if 0 if <br />V. Site Feature - Leaching Potential Analysis <br />R <br />E <br />condition <br />is met <br />R <br />E <br />cord it ion <br />is met <br />R <br />E <br />condition <br />is met <br />Minimum Depth to groundwater from the Soil Sample (feet) <br />>100 <br />51-100 <br />25-50\1 <br />Fractures in subsurface (applies to foothills or mountain areas) <br />(] <br />None <br />Unknown <br />Present <br />Average Annual Precipitation (inches) <br />xxxxxx <br /><10 <br />9 <br />10-25 <br />xxxxxxx <br />26-40\2 <br />Man -Made conduits which increase vertical migration <br />of leachate (i.e., septic systems, water wells, ponds) <br />None <br />Unknown <br />Present <br />Unique site features: Recharge area, coarse soil, nearby wells. <br />xxxxxx <br />None <br />At least <br />one <br />More than <br />one <br />COLUMN TOTALS»>TOTAL POINTS <br />+ + <br />Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br />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 />Sample Result: <br />GASOLINE 1000 100 10 <br />MAXIMUM ALLOWABLE TPN LEVELS (PPM) 100 <br />TPH DIESEL 10,000 1000 <br />FOOTNOTES: ***If documented soil aril/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 />VI. STAFF RECOMMENDATION/CONCLUSION <br />1. Are BTX & E or TPH Concentrations > Allowable Levels *Yes No <br />2. Recommend Site Yes *If Closure No Yes, Refer to Site Mitigation for Evaluation <br />__ __ <br />.... • n.mm,n cno /CCY trip <br />VI, <br />. RLVILw CVALUR"u- - w — ..– • --•-- - -- --- - <br />CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES <br />DATE REFERRED / / DATE CLOSURE LETTER MAILED <br />NAME OF <br />EH 23 80 (UGTWKSHT)\5/90 <br />