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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I. UGST WORKSHEET FOR SITE CLOSURE EVALUATION ATE /'�//�j /"71/p <br /> AME OF FACILITY TO , WEEPS CODE ��5 <br /> DRESS �O �(� ����/�� ' c ANK ID # <br /> TANK SIZE FUEL TYPE ///(/� 7 <br /> 11. GENERAL SITE HISTORY <br /> :e <br /> Is permit current7 es o ermit # - acility status Code zi oc.Soil/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if available) ype of Tank, tsl _ Fbrgl I ngl Dual <br /> 111. TANK HISTORY <br /> Jas Tank tested? es o ailed precision test 7 as o if yes, give date(s) <br /> as a repair made to the tank system? IYes No 1 11f yes, what was repaired? <br /> Jas repair done under inspecti on7 as 1 40 ere soil samples analyzed? es I o I TXE PH-G PH-D b/EDB <br /> Type of failure/discharge atastrophic long-term leakage verfitl I known I lother: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received as o. epth to Ground Water 3i34of/Year 56 $j verage Annual Precipitat' = 4 0-25 <br /> -Site Wel l(s) es o umber 8 Type Irr am ub <br /> S core S 3core <br /> istance to Well(s) from Tankft; ft; ft C 0 pts C pts C pts <br /> 0 if 0 if <br /> R ondition R ondit ion 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 Sade (feet) >100 1-100 25.501 <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) xxxx 00 10-25 Kmxmx 26-40L <br /> -an-Made conduits which increase vertical migration <br /> f leachate (i.e., septic systems, water wells, ponds) None l Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. At least 4ore than <br /> xxxx None one one <br /> COLUMN TOTALS»>TOTAL POINTS 1 /0 + p' + �t cZ <br /> ample Result: (B T X OR E) RANGE OF TOTAL POINTS 9 pts or more 41 - 48 pts 40 pts or less <br /> E — B T X E 8 T X E <br /> I ���"pd`� MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 '1. 1. NAL <br /> ample Result: ASOLINE 1000 -___1O, 10 <br /> AXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> c7 ?JO TPH IESEL 10,000 1000 100 <br /> OOTNOTE S: •••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. PP^� pPmn (diesel). <br /> L Levels for BTXBE are not applicable at a TPH concentration of 10 (gasoline) or 100 <br /> Vl. STAFF REC"ENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPN Concentrations > Allowable Levels Yes o <br /> 2. Recommerd Site Closure as o If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> 17 <br /> ONCUR WITH STAFF RECOFOR C 0 EFERRED TO 517E MITIGATION FOR EVALUATION ES 0 <br /> MMENDATION LOSUf(E ES <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> "VALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />