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SAN JOAOUIN CWNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA 11DIVISION <br /> 1, UGST WORKSHEET,,F`OR SITE CLOSURE EVALUATION ATE <br /> l:,( <br /> RME OF FACILITY I ��,Q <br /> YDS C.t]",lC/•-Q W y' EEPS CODE <br /> DDRESS rf d N , Chuv-c h -31- Lo c 1 ANK ID # o/ <br /> TANK S12E �GJ-p UEL TYPE (yu(- <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es o ermit # acil ity Status Code Tj I oc.Soil/GW Cont esEETI <br /> umber of Tanks at facility t ge of Tanks(if available) Un ype of Tank IS <br /> teel rgl IS <br /> ngl Dual <br /> 111. TANK HISTORY fle-l.tpvl 4• S <br /> as Tank tested7 as o IFailed precision test 7 es o I If yes, give date(s) <br /> as a repair made to the tank system? es No yes, what was repaired7 <br /> ns repair done under inspection? as qo ere soil samples analyzed? es TXT <br /> ype of failure/discharge atastrophic Iong-term leakageverfill nown 1 10ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .oil Samples Received as o epch to Ground Water ?� cf/Year (1'8b verage Annual Precipitation = 4 10-25 <br /> -Site Well(s) as o I umber & Type Irr om W <br /> S Score 5 Score S Score <br /> istance to Wells) from Tank ft; ft; ft - C 10 pts L 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R ondition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet) ��g�(�� >100 1.100 10 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None R Unknown resent <br /> verage Amual Precipitation (inches) KxXxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> nn-Made conduits which increase vertical migration n <br /> f leachate (i.e., septic systems, water wells, ponds) None `'l Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wells. At Least lore than <br /> X%XXX Non¢ one {{�� one <br /> COLUMN TOTALS>>>TOTAL POINTS Nal + U 3 <br /> Bmple RResuIPPM ' X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> T 390 ppm B T X E 6 T X E <br /> 9 WDC' GPM MAXIMUM ALLOWABLE B•T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1 1. NA\3 <br /> -ample Result: ASOLINE 1000 100 10 <br /> 1 �QOO AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 1 Prw TPN_.Jaa IESEL 10,000 1000 100 <br /> OOTNOTES: ***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 4=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION /j��yy�J ND4C: ,plPivl� etlll pvesc & <br /> 1, Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o fD✓.u.a -14 vv- to <br /> ✓wun cktSPerl7Gt YX1/t Lm I" <br /> 2. Recommend Site Closure es o If Yes, Refer to Site Mitigation for Evaluation £DB tpD(9) zpi'P, <br /> VII, REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR Totw4�b- NPS <br /> .ONLUR WITH STAFF RECOMMENDATION FOR CLOSURE 'ES '0 I Ef ERRED TO SITE MITIGATION FOR EVALUATION ES 10 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />