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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL eAALTH DIVISION <br /> 1• UGS7 WORKSHEET FOR SITE CLOSURE EVALUATION ATE 3a <br /> 0.ME OF FACIL17Y EEPS CODE ,2,KZC>.00W O 02, <br /> DDRESS �' ANK ID # <br /> r <br /> ANK SIZE �r?tCD #00UEL TYPE , D. <br /> 11. GENERAL SITE (STORY <br /> is permit current? ks o ermit # I lFacitity Status Codeoc.Soil/GW Cont esall <br /> umber of Tanks at facility he of Tanks(if available) IType of Tank teal Fbrgl nBl Dual <br /> Ill. TANK HISTORY <br /> Was Tank tested? es IFailed precision test ? as o 1f yes, give date(s) <br /> as a repair made to the tank system? as No f yes, what was repaired7 <br /> as repair done under inspection? eB 1 40 ere soil samples analyzed? ITas to TXE I ITPH-G PH•D I b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verfill known ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE D T JLS/COLLECT DATA,, LEfAING POTENTIAL ANALYSIS) <br /> Soil Samples Received es o epth to Ground Water of/Year I q6� verage Annual Precipitation k= 4 10-25 <br /> -Site Wells) Ifes p J r 8 Type I Irr I am I ub <br /> S core S Score S icore <br /> istance to Wel t(s) from Tank I _.�2 NIL-ft; ft; ft C 10 pts C 9 pts C i pts <br /> 0 if 0 if 0 'f <br /> R condition R conditi on R ondition <br /> 0. Site Feature - Leaching Potential Analysis E is met E is met E 's met <br /> inimum Depth to groundwater from the Soil Sample (feet) 3 _!YS%L >100 1-100 50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) None 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, water wells, ponds) None / Unknown resent <br /> inique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxxx None one one <br /> is S <br /> COLUMN TOTALS»>TOTAL POINTS * + <br /> -a-m),p�lyye��Result: (B T XpOyRE) RANGE OF TOTAL POINTS 9 pts or more 41 48 s 40 pts or less <br /> 4/(\vim /•D© ?I ' B T X E B <br /> MAXIMUM ALLOWABLE 0-T•X•E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1 NA\3 <br /> Sample Result: ASOLINE- 1000 100 10 <br /> AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> TPH 1,IESEL 1 10,000 1000 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (ie., 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 > llowable Levels Yes o 3/fL <br /> 2. Recommend Site Closure e_s o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE C011PLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 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 />