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SAN JOAQUIN TY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE._ DIVISION <br /> (' '* GST WORKSHEET FOR SITE CLOSURE EVALUATION `r ATE <br /> AME OF FACILITY 1" e- SC MGIC ♦'6 l0 —1 <br /> l�L�C.VhL Il(�✓1 U(S'h-�[�" EEPS CODE �3Cf <br /> DDRESS 31i CJO W <br /> C ANK ID p <br /> ANK SIZE 5 D UEL TYPE Re �45 <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es o ermit a acil ity Status Code 66 1Doc.S0it1GW Cont os o <br /> umber of Tanks at facility ge of Tani available) ram ype of Tank tee( rgl 1 6rat Dual <br /> Ill. TANK HISTORY tq P y <br /> i A,21n 8 9 <br /> ms Tank tested? es o ailed precision test ? es o If yes, give dates) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> ms repair done under inspectiont es qo ere soil samples analyzed? es )0 TXE N-G -D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verfill nknown I loCher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received es Y o epth to Ground Water `p of/Year ;-5/ verage Annual Precipitation = 4 10-25 <br /> •Site uel l(s) es o umber 8 Type 11r em ub 1�_ <br /> S Score 5 core S icore <br /> istance to Well(s) from Tank ft; ft; ft C 10 pts C pts C i PIS <br /> 0 if 0 1f 0 'f <br /> R ondition R onditi on R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater frau the Soil Sample (feet) >100 1.100 C 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None 67 Unknown Fresent <br /> verage Annual Precipitation (inches) xxxxx <10 9 10-25 xxxxxxx 26.40%2 <br /> on-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds). None Unknown J resent <br /> )nique site features: Recharge area, coarse soil, nearby wells. At least r ore than <br /> xxxx None / one /J- one <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> ample Result: (B T X ORr EEY11)� RANGE OF TOTAL POINTS 9 pts or more 41 48 pts 40 pts or less <br /> Np o�r �IGn 6 i X E 8 T X E <br /> MAXIMUM ALLOWABLE B-T-%-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> -ample Result: ASOLINE 1000 100 10 <br /> AXIMUN ALLOWABLE TPH LEVELS (PPM) <br /> TPH IESEL 10,000 1000 100 <br /> 7 7 •--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 £t. and c 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 net applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION nEvatuatiw:-O�� <br /> Arc BTX 8 E or TPH Concentrations > Allowable Levels Yes2. Recomend Site Closure Yes I �10 I YIf Yes, Refer to Site Mitigation for U <br /> VII. REVIEW EVALUATION • TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES I 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> 0.ME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> rx 29 80 <br />