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SAN JOAOUIM�06NTY PUBLIC HEALTH SERVIGS/EHVIRCNMENTAL :iEA:.. OIVISION I — <br /> I UGST WORKSHEET FOR SIITEc+CLOSURE EVALUATION OATS oV <br /> NAME OF FACILITY II CALL Q N jv C /4 Fa e6 J ISWE.oS CODE) O . <br /> ADDRESsl 3 l #-7 -5 T—� ,, - nd'a (TANK LD At <br /> ITANK SIZEI /O�©D� (FUEL TYPEIDiQ.XLI DI pf p, 1 ` <br /> II. GENERAL SITE HISTORY <br /> Is permit current?IYes Na IPemit 3 - Facility Status Codel 0 / )Doc-Soi L/GW Cant I Yesl INoI <br /> Nunber or Tanks a[ facility )Age of Tanks(if available) (Type of Tanki Steell lFbrgl lsmtl DUaL <br /> III. TANK HISTORY L.:>...s .3A- 3Q 6TK� <br /> Was Tank tested? Yes Na IFaited precision test ?IYesl IJoe I if yes, give date(330131 //U' <br /> Was a repair made to the tants systm?l Yes go Iif yes, what was repaired?1'4-t- f&'0�0✓aAdw— <br /> Was repair done under inspection?Fes INoI IWere soil saooles analYiee?I Yes INoI aTXEI ITPN-G TPN-O Pb/EDBI <br /> Type of failure/dischargel Icatastraphicl ILang-term Leakage) Ioverfilll Iunknonl lather: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTICN REPORT FOR SITE DETAILS/COLLECT DATA FOR 1.EACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received IYesl No IOepth to Grand Water IRef/Year IAverage Annual PreeipitaCionlAa 14. 10-25 <br /> On-Site WeIL(s)IYesl Na INumber a Type Ilrr lapel IPual S Score S Score S Score <br /> Distance to Wells) froe Tank) ft; ft; ft C 10 pts C 9 pts C 5 PCs <br /> 0 if D if o if <br /> R candition R condition R condition <br /> V. Site Feature - Leaching Potarrcia/ AMLYsis . - is met is mK C is met <br /> Minimus Depth to groundwater from the Soil Sample (feet) l I -1013 I I51-100 I 125-30\1 <br /> Fractures in subsurface (applies to foothills or mountain areas)' I None I I Unknown (Present <br /> Average Annual Precipitation (inches) srxroDcl <10 I 9 l 10-25 1=00=1 25-40\2 <br /> i <br /> (Man-Made conduits which increase vertical sigratim <br /> of Leachate (i.e., septic system, water wells, ponds) None lNtk)haen I Present <br /> Unique site features: Recharge area, coarse soil, nearby welts. I I At least) (More than <br /> l0== None ane one <br /> rE- D 15 r,? *D COLUMN TaTALD»TOTAL POINTS <br /> to Result: (B T XOR ?) RAMGE OF TOTAL POINTS 49 pia or more I l - :d m :0 acs or Less <br /> O;D(V'10 U MAXIMUM! ALLOWABLE 3-T-X-a LEVELS (PPM) 1I 50 50I 50 I .3 .3 I 1.1 <br /> 1. I NA\3 j <br /> Sample Resu N b GASOLINE 1000 I 100 i 10 <br /> 0 ld.pv _ hh MAXIMDI ALLOWABLE TPN LEVELS (PPM) <br /> TPH J DIESEL 10,000 l 1000 100 <br /> :A If docnmahted soil ardor grand water contamination is present, do rat camulete the Leaching potential <br /> aatysis. (i.e., site is currently an UGT Contamination List for soil or ground water.) <br /> X: N \1 If depth is > 5 ft. and < 25 ft., spm 0 points. If depth <9 It., do not use -sole_ <br /> \2 If precipitation is > 40 inches, score 0 paints. <br /> \3 Levets for BTXEE arc not applicable at a In concentration of 10 ppm (gasat ine) or 100 poe (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 3 E or TPH Concentrations > ALLweble levels I"ft INoI <br /> i <br /> 2. Recommend Site Closurel Teal INoI L If Yes, Refer to Site Mitigation for Evaluationl, <br /> VII. REVIEW EVALUATION - TO BE COMPLETED 3Y A SUPERVISOR/SENIOR <br /> CONCUR WITH STAFF RECOIENOATICM FOR CLOSUREITESI IND+ IRE-ERRED TO SITE MITIGATION FOR EVALUATIOMIYESI INOI <br /> DATE REFERREDI / / DATE CLOSURE LETTER MAILS <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />