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SAN JOAQUIN C' Y PUSLIC HEALTH SERVICES ENVIRONMENTAL NEA " IVIS20N <br /> t.. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILI EPS CODE <br /> ODRESS ANK t <br /> ANx SIZE " } t3 TYPE <br /> It, GENERAL SITE HISTORY <br /> t rai car tT rsrsi t ani t i ty Stas C' raa llG Cant es <br /> 0 <br /> r of Tates fAci i Se a ''Tan s{ labte Tank teat br l n9t owl <br /> 1'21n TANK HISTORY <br /> 'as Tank testIf yes, give date(s) / � <br /> as a repair epairedl <br /> AS repair r inspedti 7 ere snit l:es anaLyzedY es to THE PH.G PH-0 b/EDS <br /> Yf a failtredischarge aastaai t gate leakage verTitl r'+ n n thr< <br /> tv. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ail Sairptes Received as a epth to Ground totemeflYear> � ' r verage A t Precipitation � 4 ' 0425 <br /> -Site Well($) es X o unber S Type Irr cab <br /> S care S core Score <br /> ista 'e to LPtt(s) from Tank ft; ft C 0 Pts C pts C pts <br /> 0 0 if O f <br /> R ondition A onditionR ondition <br /> Site Feature - Leaching Potential Analysis E s ffet E is met E s met <br /> imixAo Depth to groundwater from the Sant Sampte (feet) >100 1.100 25-50\1 <br /> ractures an subsurface (appties to foothills or mountain areas) None Unknown resent <br /> vera+Se Annual Precipitation (inches) xxxxx 'CIO 9 10.25 xxxxxx 26-40\2 <br /> 2 <br /> -Made co its which increase vertical migration <br /> f leachate (ie., septic system, water wells, p s) None Unknown resent <br /> Inique site features: Recharge area, coarse sail, nearby wells. At teast are thea <br /> xxxxx Rome one one <br /> COLUMN TOTALS TOTAL POINTS C + + <br /> arr to Result: (0 T X 0R E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 Fats or less <br /> S T It E S T X E <br /> MAXIMUM ALLOWABLE 8-T-H-E LEVELS ( al) 1 50 50 50 .3 ,3 1. 1m CNA <br /> smote Result* A OLINE 4000 100 10 <br /> °i O) l A IMUM ALLOWABLE TPH LEVELS (RPM) <br /> TPH I SELL 10,000 1000 100 <br /> t tP10TE5: ***If doctminted suit and/or ground water contamination is present, do not ctaptete the leaching pot tint <br /> analysis. i.e. site is currently on UGT Contamination List far sail or grotoxi water.) <br /> \1 if depth is 5'ft. and c 25 ft„, scare 0 points'. if depth <»5 ft., do not use table, <br /> t' ;2 If precipitation is 0 inches, scare 0 Meats. <br /> Levels for ST &E are not appticabLe at a TPH concentration of 10 ppm (gasoline) or 100 ppim (dieset)< <br /> VI. STAFFRECOMMENDATION/CONCLUSION <br /> 1. Aro STS E or TPH cpnratip a` Allouab Levet Yes o � _. <br /> 2. Rcc erg Site ostare es o f Tee, Refer to Sate Nstagati far Evi��ati <br /> V l< REVIEW EVALUATION ^ TO BE COMPLETED BY A U ERVI OR/SENTOR <br /> E <br /> E OMMENOATI N FOR CLOSUR E 0 EF BRED TO SITE MITIGATI FOR EVALUAT OrP EStkl l ATE CLOSUR LETTER ILEta 1 <br /> EN 23 80 (UGTW SHT) 5/ 0 <br />