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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA II DIVISION <br /> 1. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE <br /> AME OF FACILITY �U ,�» �Uw� WEEPS CODE <br /> DRESS /(/, �/i q��.r� ANK ID R <br /> TANK SIZE 1,UEL TYPE //Zl �'� /�[-e1PGa✓c< idy a�� ��" <br /> 11. GENERAL SITE HISTORY <br /> e� <br /> Is permit current? es I o ermit M - acility Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) IType of Tank- tee Fbrgl ngI Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested? es IHO ailed precision test 7 es o If yes, give date(s) <br /> Jas a repair made to the tank system? Yes No f yes, what was repaired? <br /> as repair done under inspection? es o ere soil samples analyzed? es o TXE PN-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verfill I nknown I ther: <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 "'<., of/Year 4 u ; �— 3 Ikverage Annual Precipitation_ 0-25 <br /> -Site WCII(s) IYes I o umber 8 Type Irr am I ub <br /> S core S core S core <br /> istance to Well(s) from Tank I ft; ft; ft C 10 pts C pts C i pts <br /> 0 if 0 if 0 if <br /> R onditi on R ondition 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 17 25.501 <br /> Fractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) KXXXXX <10 9 10-25 mxxxx 26.40 2 <br /> an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) (O None Unknown resent <br /> nique site features: Recharge area, coarse soil, nearby wells. At least ore than <br /> xxxxx None one one <br /> COLUMN TOTALS>»TOTAL POINTS Ir i <br /> 2,a PP r RA E OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> ample Result: (B T X ORE) _ _, <br /> T % E 8 T % E <br /> "76 jrry MAXIMUM ALLOWABLE B•T-X-E LEVELS (PPM) 1 50 50 50 3 .3 1. 1. NAl <br /> mple Result: - ASOLINE 1000 T60 10 <br /> '�;D TPH <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) 1000 100 <br /> IESEL 10,000 <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 UGI 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 TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Pre BT% 8 E or TPH Concentrations,> Allowable Levels Yes o <br /> 2. Recommend Site Closure es o . g0a <br /> Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SU1. <br /> ONCUR WITH STAFF RECOMMENDATION FOR CLOSUREED TO SITE MITIGATION FOR EVALUATION ES KI 0ATE REFERRED / ` / U AILED / / <br /> AME OF <br /> "VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />