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SAN JOAOUIN i fY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE&�, DIVISION ATE 1• - 4 <br /> I. `UGST WORKSiHEEET FOR SITE CLOSURE EVALUATION ,I <br /> JG.�•�Q. YV�O I v C� EPS CODE -z 6 Ll. <br /> AaE OF FACILITY �3'lf'lG ANK ID N 3 9 - cP qy- oI <br /> DDRESS IO OO N pt)r 2 d O <br /> TANK 512E UEL TYPE <br /> 01 — 1lJ 45_ - L I/ODO.� Z. <br /> D-Z - Unlaac�d urn kvL°�✓`"` <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? es o <br /> Permit <br /> p acility Status Code 5 d oc.SoiL/GW Cont es o <br /> umber of Tanks at facility '� 9 <br /> e of Tanks(if available) ype of Tank teal rgl rgl Dual <br /> Y, ,—t,K'- - ✓nl�r.owr� <br /> 111. TANK HISTORY Y4rVN0Uecx q•II -S- <br /> as Tank tested? Ifas o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> ns repair done under inspection? es o ere soil samples analyzed? es TXE H-G -D b/E08 <br /> Type of failure/discharge atastrophic long-term leakage verfill nknown Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Ail Samples Received Ifas o epth to Ground Water I a of/YeaMmtE <br /> Annual Precipitation = 4 10-25 <br /> -Site WeI L(s) as o umber 8 Type Irr am uU <br /> core S core <br /> istance to Well(s) from Tank ft; ft; ft pts C pts <br /> if 0 if <br /> ondition R ordition <br /> V. Site Feature - Leaching Potential Analysis is met E is met <br /> inia<xm Depth to groundwater from the SoilSample (feet) >100 1.100 25.50%1 <br /> ractures in subsurface (applies to foothills or mountain areas) I None Unknown Present <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 Present <br /> Inique site features: Recharge ea, coarse soil, nearby wells. At least ',_r ore than <br /> xxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS <br /> ample Result: (8 T % OR E) RANGE OF TOTAL POINTS 9 pts or more 48 pts 40 pts or Less <br /> WID�1 �✓� Ppiq \ 8 T X E IS <br /> 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 /> TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: ***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 r_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 NO lm ectl)✓ 6+'t I 4 VQ yylLJj O✓ •SYw Y✓V�l.t�� <br /> 1, Are BTX 8 E or TPH Concentrations > Allow ble Levels Yes I V�o <br /> 2. Recommend Site Closure es o I If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW REVIEW EVALUATION • TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ESI <br /> 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES O <br /> ATE REFERRED / / ATE CLOSUREeL TER MA• LED <br /> AME OF n •� /, _ <br /> .VALUATOR �, ): 11 L <br /> - <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> Ex 29 80 <br />