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SAN UOAOUIN COUNTY PUBLIC HEAL TN SERVICES/ENVIRONMENTAL HEALTH DIVISION1. <br /> UGST WORKSIIEET FOR SITE CLOSURE EVALUATION ATE <br /> / WEEPS CODE ��p <br /> AME OF FACILIT <br /> ANK ID N <br /> DRESS a p 6 d e <br /> TANK S12E 1000 UEL TYPE I- Sed <br /> 11. GENERAL SITE HISTORY (� » <br /> Is permit current? es o ermit Y - ecil i[y Status Cade ae.Soi l/LW Can[ ee o <br /> g <br /> e of Tanka({f available) Type of Tank toel F1F1,10 ag <br /> rl <br /> umber of Tanks at facility. Dual <br /> III. TANK HISTORY <br /> as Tank tested? es o ailed prec kion test 7 ee o If yes, give date(s) <br /> as a repair made to the tank system? es No f yes, what was repaired? <br /> aples s repair done under Inspection? as' o ere soil samanalyzed? es o IT%E IVN•G PN-D b/EDB <br /> type of failure/discharge .atastroph is longterm Leakage verf ill mown [her: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Staples Received es o ep[h to Ground Water of/Year , <br /> verage Annual Precipitation • 4 110-25 <br /> -Site Vell(s) es o umber A Type Irr Ola ub S core S core S core <br /> istance to WeLI(s) from Tank ft; ft; ft C 0 Pts C pts C Pta <br /> O it O of O if <br /> --_—__ R :ondition R edition R ondi t i on <br /> Site feature - eaching Potential Analysis E is met E is met E is act <br /> ti ninon Depth to grourdwot er r Sample (feet) <br /> >100 1-100 25-50.\1 <br /> rnc[ures in subsurface (applies to foothills or mountain areas) None <br /> Unknown resent <br /> verage Arcual Precipitation (inches) xxxxx 00 9 10-25 xxxxxx 26-4022 <br /> an-Made conduits which increase vertical migrationUnknown resent <br /> I leachate (i.e., septic systemNones, water wells, ponds) " <br /> At least ore than <br /> pique site features: Recharge area, coarse soil, nearby wells. Xxxx None one one <br /> i , I } <br /> COLUMN TOTALS»>TOTAL POINTS F > O's <br /> ample Result: (B 1 % ON E) RANGE OF TOTAL POINTS .9 pts or more 41 - 45 It 40 pts or less <br /> 7 rSPGh/ b•NPoh- <br /> L QL = 3•s) 3� PPn` MAXIMUM ALLOWABLE B-T-%-E LEVELS (PPM) 1 50 50 50 .3 .3 x. 1. NAL <br /> 1000 100 10 <br /> ample Result /� <br /> : ? <br /> 'ASOLINE`/a AXIMJM ALLOWABLE TPN LEVELS (PPR) iESEL 10,000 1000 100 <br /> I TPH <br /> -001NOTES: "•If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> anatysis. (i.e., site is currently on UGT ContantirRI List for soil or ground water.) <br /> \11- 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 /> L Levels for BT)I are not applicable at a TPH concentration of 10 Ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION C-I_/ <br /> 1. Are BTX A E or TPN Concentrations > Allowable Levels Yes 0 <br /> 2, <br /> Recommend Site Closure es o If Yes, Refer to Site Mitigation for EveluaC{on <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSLN(E ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES 0 <br /> ATE REFERRED / / AlE CLOSURE LETTER MAILED / / <br /> AME OF 11 <br /> VALUAJOR <br /> IN 23 80 (UGTWKSHT)\5/ <br />