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SAN JOAQUIN Cow..,Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA DIVISION ' q <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ~ ATE �. / <br /> AME OF FACILITY el.AJ d-�I /�\ GEEPS CODE �O Z(' <br /> DORESS -4 &a,5} �it�4l'I,�if� HC�.ry-1 IT ANK 10 # I <br /> TANK SIZE IFUEL TYPE 1,600,9+0 AICG>— 37- vo-70— Dz- <br /> II. GENERAL SITE HISTORY E '3-W <br /> Is permit current? es o ermit # acility Status Code 5a oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) Ype of Tank teel Fbrgl ngl Dual <br /> Ill. TANK HISTORYIV_41&Jleal to.m.7-4 <br /> .as Tank tested? es o ailed precision test ? as 8o If yes, give date s) / <br /> as a repair made to the tank system? Ifes No f yes, what was repaired? <br /> Pis repair done under inspection? as o ere soil samples analyzed? es o 1XE PH-G PH-0 b/EDO <br /> Typo of failure/discharge atastrophic long-term leakage vert ill nknown Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .oil Samples Received es 1401 epth to Ground Water qb of/Year I apt verage Annual Precipitation = 4 10-25 <br /> -Site Well(s) as o umber 8 Type Irr 0M ub <br /> S Score S Score S core <br /> Distance to Welt(s) from Tank ft; ft; ft C 10 pts L 9 pis C pts <br /> 0 if 0 if O f <br /> R ondition R condition R ondition <br /> V. Site Feature - Leaching Potential Analysis E is met E is met E s met <br /> inimum Depth to groundwater from the Soil Sample (feet) >100 1-100 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None Q` Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, Mater wells, ponds) None Unknown resent <br /> Iniciue site features: Recharge area, coarse soil, nearby wells. At least lore than <br /> xxxxx None one 5 one <br /> COLUMN TOTALS>A>TOTAL POINTS <br /> a le Result: (B T % OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T % E <br /> .D1pf W 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 /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> DPYYITPH IESEL 1 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 UCT 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, store 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION No (py\ w'Ct TlcY A r.QMOV <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable levels Yes o <br /> 2. Rec omnend Site Closure 1Yes I o If Yes, Refer to Site Mitigation for Evaluation <br /> V11. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES O EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> :'JALUA TOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />