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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE �Z•Z�! •�13 <br /> AME OF FACILITY WEEPS CODE 113 z <br /> DDRESS 1 $O5 �.0 }- 1,0✓ jzc� s-r}G.VZ F!5203 ANK ID # 131- 1132- <br /> TANK SIZE .�,r�jgyQ UEL TYPE <br /> II. GENERAL SITE HISTORY <br /> is permit c 0 ermit # acility Status Code S oc <br /> ( .SoiL/GW Cont 10 <br /> urrent? esIF <br /> umber of Tanks at facility . he of Tanks(if available) tlyy-s IType of Tank Ii teal �tbrgl I ISngl I Dual <br /> III. TANK HISTORY <br /> Pas Tank tested? Ifes , o ailed precision test ? as o If yes, give date(s) <br /> Jas a repair made to the tank system? Fas No f yes, what was repaired? <br /> ns repair done under inspection? es o ere soil samples analyzed? es !o TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verfill Frown cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> .oil Samples Received as o epth to Ground Water 15 of/Year [51 verage Amus( Precipitation = 4 10-25 <br /> )n-Site Wells) es o umber 8 Type Irr om ub <br /> S 3core 5 Score S Score <br /> istance to Wells) 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 /> v. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Sample (feet)15- EJes >100 1-100 O 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) I b None Unknown resent <br /> verage Annual Precipitation (inches) Kxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> nn-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. q At least ore than <br /> xxxxx None 1 one one <br /> COLUMN TOTALS>>>TOTAL POINTS (c) + �,�' 3 T <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> T- 4oPQm /1 1 <br /> BFB-)4 - IJ ogC)jN) MAXIMUM ALLOWABLE B•T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> -ample Result: ASOLTNE 1000 100 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> a0ppn'1 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 LOT Contamination List for soil or ground 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 /> VI. STAFF RECOMMENDATION/CONCLUSION 1, <br /> 1, Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o r�'�l/JI V <br /> I2. Recommend Site Closure lY as I f10If Yes, Refer to Site Mitigation for Evaluation <br /> VII, 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 10 <br /> ATE REFERRED / / ATE CLOSURE LETTER NAILED <br /> AME Of <br /> VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />