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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION Q <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE 2,2q— lJ <br /> NAME OF FACILITY heh; Ltd Q0✓V� Vj WEEPS CODE ��3� <br /> ODRESS C)✓• 5•Yti n IJ�D'3 ANK ID # <br /> TANK S12E �O�OJ�O�a.P UEL TYPE 1� <br /> 11. GENERAL SITE HISTORY <br /> Is permit co rmit # acility Status Code 6'toc.Soil/GW C <br /> urrent? es es o <br /> umber of Tanks at facility ge of Tanks(if available) [Type of Tank teel rqt ngl I Dual <br /> III. TANK HISTORY ret>v.ae I.S <br /> tM 4a tl[�t � <br /> as Tank tested? as o ailed precision test ? es o If yes, give date(S) <br /> as a repair made to the tank system? IYes No f yes, what was repaired? <br /> ns repair time under inspection? es No re soil samples analyzed? es Jo TXE I PH-G I PH•D b/EDO <br /> ype of failure/discharge atastrophic long-term leakage I <br /> verf ill Known Cher: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> ,oil Samples Received es o epth to Ground Water 1 IS cf/Year verage Annual Precipitation = 4 10-25 <br /> -Site Well(s) eso umber 8 Type Irr om ub <br /> S Store S Score S Score <br /> istance to welt(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 /> V. Site Feature - Leaching Potential Analysis E is met E is met E is met <br /> inirtum Depth to groundwater from the Soil. Sample (feet) 15442-2 >100 1-100 D 25-50\1 <br /> ractures in subsurface (applies to foothills or mountain areas) Ib None Unknown resent <br /> verage Annual Precipitation (inches) KAXXXX <10 9 10-25 xxxxxxx 26-40\2 <br /> Mn-Made conduits which increase vertical migration p <br /> f leachate (i.e., septic systems, water welts, ponds) None -I Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby welts. At least ore than <br /> cxxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS jo + 3 S- <br /> ample Result: (0 T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> U 1 14(>i STX <br /> 0a 14o B T X E B T X E <br /> MAXIMUM ALLOWABLE O-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> -ample Result: ASOLINE 1000 100 10 <br /> Ut 140F1rM AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> U2 at{PPM TPH IESEL 10,000 1000 100 <br /> OOTNOTES: ***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 <=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 / n� <br /> 1, Are BTX 8 E or TPH Concentrations > Allowable Levels Yes o <br /> I2. Recommend Site Closure es ro If Yes, Refer to Site Mitigation forvalu <br /> Eation <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 O <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br /> EH 29 80 <br />