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SAN JOAQUIN CCUNTY71JBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DWISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> .4HE OF FACILITY EEPS CODE <br /> DDRESS S7 ARK ID # LZ —Q <br /> ANK SIZE (, ')00 UEL TYIE r <br /> 11. GENERAL SITE HISTORY _ <br /> III's permit current? es o ermi[ # acility Status Code oc.Soil/GW Cont es 10 <br /> ryunber of Tanks at facility 9e of Tanks(if available) I IT ype of Tank teal brgl ngl Dual <br /> lilt. TANK HISTORY <br /> :as Tank tested? Ifes o ailed precision test ? Ifes o If yes, give date(s) <br /> as a repair made to the tank system? es I No 17f yes, what was repaired? <br /> ms repair done under inspection? es o ere soil samples analyzed? es 10 TXE PH•G PH-D b/EDO <br /> Type of failure/discharge atastrophic long-term leakage verfill known 1 10cher: <br /> Iv. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samples Received as 100 epth to Ground Water /0 of/Year � verage Annual Precipitation Nz 4 10.25 <br /> 3n-Site Welts) es o umber G Type Irr bomub <br /> S Score S Score 5 Score <br /> )istance to Well(s) 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 condition R ondition <br /> 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 /> Fractures in subsurface (applies to foothills or mountain areas) /b None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 Kuxxxx 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 leas[ 4orc than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS / + + <br /> AL— <br /> Sample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 • 48 pts 40 pts or l s <br /> "C I O <br /> r 4S ��/ G i X E 3 T X E _--- <br /> x to MAXIMUM ALLOWABLE G-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1• 1. NA\3 <br /> ample Result: ASOLINE 1000 100 10 <br /> AXIMUM ALLOWABLE TPN LEVELS (PPM) <br /> W IESEL 1 10,000 1000 100 <br /> COTNOTEES: *--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 4=5 ft do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for 8TX8E are not applicable at a TPH concentration of 10 ppn (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION ,1� ,�/ y- <br /> �J <br /> 1, arc GTX 8 E or TPM Concentrations > Allowable Levels Yes o <br /> / <br /> 2. Recommend Site Closure tes <br /> o f Yes, Refer to Site Mitigation for Evaluation <br /> V. 1. REVIEW EVALUATION • TO BE COMPLETED 0Y A SUPERVISOR/SENIOR —7 <br /> -ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED TO SITE MITIGATION FOR EVALUATION ES I10 I I <br /> ATE REFERRED , ATE CLOSURE LETTER MAILED <br /> i I <br /> 4° OF <br /> .JA:VATUR <br /> EH 23 8C oJGTWKGHf)A;'�, <br />