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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEAt.'TH DIVISION <br /> I, UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY • ID �}�le V1 WEEPS CODE S�I <br /> T / 1DDRESS 7ANK ID p <br /> D 1�R- }TU <br /> V ANK SIZE gL�' IA:L tY <br /> 11. GENERAL SITE HISTORY .� <br /> Is permit current? Ifes o ermit # I lFacitity Status Code oc.Soil/GW Cont es 0 <br /> umber of Tanks at facility ge of Tanks(if available) ylx of Tank teal brgl rgl Dual <br /> Ill. TANK HISTORY <br /> as Tank tested? es o ailed precision test ? es o If yes, give date(s) <br /> as a repair made to the tank system?IYes No 1 1,f yes, what was repaired? <br /> ns repair done under inspection? a3 o ere Soil samples analyzed?mesio T%E PH-G PH-D b/EDD <br /> Type of failure/discharge I atastrophie long-term leakage verfilt noun ther: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oft Samples Received es 1001 epth to Ground Water of/Year 00 verage Annual Precipitation = 4 110.25 <br /> )n-Site Well(s) es o I umber 8 Type I trr I om I ub <br /> S core 5 coreS core <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C pts C pts <br /> 0 if 0 if 0 'f <br /> R ondition R ondition R ordition <br /> Site Feature . Leaching Potential Analysis E is met E is met E 's met <br /> iniaum Depth to grourdwater from the Soil Sample (feet) 1100 1.100 E5 25.50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) I O None Unknown resent <br /> verage Annual Precipitation (inches) xxxxxx 00 9 10-25 KXXxxxx 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 fore than <br /> xXXXX None ( one one <br /> COLUMN TOTALS»>TOTAL POINTS Iv + * U <br /> ample Result: (0 T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 48 pts L 40 pts or less <br /> � 'rr NDS OSP t'L— MAXIMUM ALLOWABLE B•T-X•E LEVELS (PPM) B 50 50 50 .3 .3 1. 1. NA\3 <br /> Sample Result: ASOLINE- 1000 100 10 <br /> I.(7 PY"r, AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> 11 1 <br /> TPH IESEL 10,000 1000 100 <br /> FOOTNOTES: "'*If documented soil and/or ground water contamination is present, do not complete the caching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or gro 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 BTXBE are not applicable at a TPN concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> 2. Recommend Site Closure as o If Yes, Refer to Site Mitigation for Evaluation <br /> V11, REVIEW EVALUATION • TO BE COMPLETED 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 />