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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I• UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 2 13 <br /> AME OF FACILITY / / / EEPS CODE Q <br /> DDRESS ef, ANK ID 8 i0 <br /> TANK s12E11;66,, UEL TYPE P !d v7— d Z, <br /> II. GENERAL SITE H STORY <br /> Is permit current? es o ermit k acil ity Status Code oc.Sol l/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) IType of Tank IS test Fbrgt I ISngl I Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? IYes No 1 11f yes, what was repaired? <br /> as repair done under Inspection? as I No ere soil samples analyzed? es Jo TXE PH-G PH-D /EDO <br /> ype of failure/discharge atastrophic long-term Leakage verfill nknown 1 10ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPE TION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received as o =pthto Ground Water of/Year verage Annual Precipitation N= 4 10.25 <br /> •Site Wells) es o umber & Type I Irr I am I ub <br /> S core S Score 5 Score <br /> Istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts ` <br /> 0 if 0 if 0 if <br /> R ondition R conditi on R ondition <br /> 0. Site Feature - Leaching Potential Analysis E is met E is met E is 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 Unknown resent <br /> verage Annual Precipitation (inches) xxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> an-Made conduits which increase vertical migration <br /> I leachate (i.a., septic systems, water wells, ponds) None Unknown S resent <br /> Inique sitefeatur1es: Recharge ar a, coarse soil, nearby wells. At least ore than <br /> r" G XXXxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS + Z + �Q <br /> Sample Result: IS T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> B T X E B T X <br /> MAXIMUM ALLOWABLE B-T-X•E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: ASOLINE 11 1000 100 10 <br /> f� J AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> Ll6 /h TPH_6a IESEL 1 10,000 1000 100 <br /> DOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the teach—Itial <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 BTXSE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes <br /> 2. Recommend Site Closure as o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 I EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />